Pre-pregnancy planning for female patients seen at a pregnancy and rheumatic diseases clinic: a retrospective analysis of patients with rheumatic diseases seeking pregnancy-related care.

To assess the clinical utility of pre-pregnancy planning among female patients with rheumatic diseases attending a targeted pregnancy and rheumatic diseases clinic. We conducted a retrospective review using data collected via chart review of female patients with rheumatic diseases seen at the Pregnancy and Rheumatic Diseases Clinic at the Mary Pack Arthritis Centre in Vancouver, Canada, between January 2017 and July 2020. Patients were categorized according to an initial presentation at the clinic as (1) pregnant without pre-pregnancy planning; and (2) not pregnant with pre-pregnancy planning. The latter group was further categorized according to whether they had contraindications to pregnancy. Pregnancy outcomes were extracted from electronic medical records and analyzed using descriptive statistics. Our study included 230 female patients with rheumatic diseases. At the initial clinical presentation, 86 were pregnant and 144 were planning to become pregnant and presenting for pre-pregnancy planning. Compared to patients without pre-pregnancy planning, patients who received pregnancy planning experienced fewer prenatal disease flares (61.3% [38/62] vs. 22.6% [7/31]; p < 0.001), fewer medication changes during pregnancy (46.4% [39/84] vs. 18.9% [10/53]; p = 0.002), and improved disease control in the first trimester of pregnancy (p = 0.018). There were no statistically significant differences in the frequency of adverse pregnancy or fetal outcomes between patients with and without pre-pregnancy planning. Evaluation of patient outcomes suggests that pre-pregnancy planning may support early assessment of high-risk pregnancy status; therein, allowing healthcare providers to identify and manage risk factors for adverse pregnancy outcomes among patients living with rheumatic diseases.

Leflunomide exposure through second trimester of pregnancy: A case report.

Leflunomide is a commonly used disease modifying antirheumatic agent. However, its use is contraindicated in pregnancy. The American College of Rheumatology (ACR) guidelines recommend discontinuing Leflunomide at least 24 months before conception. If a woman is found to be pregnant while on Leflunomide, ACR suggests close monitoring and cholestyramine washout. We describe a case of a patient with a history of juvenile idiopathic arthritis who was on Leflunomide throughout the first and second trimester of her pregnancy. A cholestyramine washout regimen was started but not completed. The patient was induced at 37 weeks of gestation due to non-reassuring fetal heart rate. She ultimately delivered a healthy baby via emergency cesarian section.

"The medications are the decision-makers " Making reproductive and medication use decisions among female patients with rheumatoid arthritis: a constructivist grounded theory.

OBJECTIVE: To examine how female patients with RA form decisions about having children, pregnancy, and medication use. METHODS: We employed a constructivist grounded theory design and recruited female participants who are 18 years or older, have a rheumatologist-confirmed RA diagnosis, live in Canada, and are able to communicate in English or French. We collected data through semi-structured individual and focus group interviews using telephone or video conferencing technology. Data collection and analysis were iterative, employed theoretical sampling, reflexive journaling, and peer debriefing, and culminated in a theoretical model. RESULTS: We recruited 21 participants with a mean age of 34 years and median 10 years since RA diagnosis. Overall, 33% had never been pregnant, 57% had previously been pregnant, and 10% were pregnant at the time of interview. Of those who had experienced pregnancy, 64% had at least one pregnancy while diagnosed with RA and of those, 56% used DMARD(s) during a pregnancy. We constructed a patient-centred framework depicting the dynamic relationships between 4 decision-making processes-(1) using medications, (2) having children, (3) planning pregnancy, and (4) parenting-and the substantial impact of healthcare providers on patients' experiences making these decisions. These processes were further influenced by participants' intersecting identities and contextual factors, particularly attitudes towards health and medications, disease onset and severity, familial support system, and experiences interacting with the healthcare system. CONCLUSION: Our framework provides insight into how patients make reproductive decisions in the context of managing RA and the opportunities for providers to support them at each decision-making process. A patient-centred care approach is suggested to support female patients with RA in making reproductive and medication choices aligning with their individual desires, needs, and values.

Partners of female patients with rheumatoid arthritis and reproductive decision-making: a constructivist grounded theory study.

OBJECTIVE: Partners of patients with RA often take on supportive roles given the debilitating nature of RA. Our objective was to explore the perspectives, attitudes and experiences of partners of female patients with RA regarding reproductive experiences and decision-making. METHODS: We conducted a qualitative study involving semi-structured interviews with partners of female patients with RA. We defined a partner as an individual within a romantic relationship. Constructivist grounded theory was applied to interview transcripts to identify and conceptualize themes. RESULTS: We interviewed 10 partners of female patients with RA (10 males; mean age, 35 [23-56] years), of whom 40% had at least one child with a female patient with RA and did not desire additional children. We identified four themes representing stages of reproductive decision-making: (1) developing an understanding of RA, (2) contemplating future family decision-making, (3) initiating reproductive decision-making with partner, and (4) reflecting on past reproductive experiences. Participants contemplated their attitudes and perspectives regarding pregnancy and used available information to support their partner's medication decisions. When reflecting on their reproductive experiences, participants shared the impacts of past reproductive decisions on their romantic relationship and their mental health and wellbeing. CONCLUSION: Our study highlights the need for comprehensive support for both female patients with RA and their partners at all stages of reproductive decision-making. Health-care providers can identify opportunities for intervention that involves female patients with RA and their partners to minimize stress and its negative impacts on the family.

"Walking into the unknown " key challenges of pregnancy and early parenting with inflammatory arthritis: a systematic review and thematic synthesis of qualitative studies.

BACKGROUND: To conduct a systematic review and thematic synthesis of qualitative studies on the pregnancy and early parenting experiences of patients with inflammatory arthritis (IA). METHODS: We searched online databases for English-language, qualitative studies capturing the experiences of females with IA or their healthcare providers with pregnancy and/or early parenthood. We extracted findings from included studies and used thematic synthesis to develop descriptive and higher-order analytical themes. RESULTS: Of 20 included studies, our analysis identified 5 analytical themes among patients and 3 among providers. Patients' reproductive desires, the impact of IA on their ability to experience pregnancy, and the availability of information to guide preparedness informed their pregnancy decisions. Patients' IA management, pregnancy expectations, and access to support influenced their reproductive experiences. Patients' experiences seeking information and care revealed substantial gaps in reproductive care provision to patients with IA. Reproductive uncertainty related to IA placed a heavy burden on patients' emotional and psychological wellbeing. Reproductive care provision was influenced by providers' perceived professional responsibility to address patients' reproductive goals, fears of negative outcomes, and capacity to harness patient trust, incorporate reproductive care into rheumatology practice and facilitate multi-disciplinary care coordination. CONCLUSIONS: Our review illuminated several barriers to experiencing pregnancy among patients with IA, particularly related to pregnancy planning support, availability of information, and care coordination among the patient's healthcare team. To improve care, these barriers may be mitigated through the provision of relevant, practical, and consistent information as well as patient-centred multi-disciplinary approaches for managing pregnancy among patients with IA.

Perinatal exposure to conventional synthetic disease-modifying anti-rheumatic drugs in women with rheumatic disease and neonatal outcomes: a population-based study.

OBJECTIVES: Epidemiologic studies evaluating associations between specific arthritis medications and perinatal outcomes are limited. We evaluated the association between conventional synthetic DMARD (csDMARD) use among women with rheumatic disease (RD) and neonatal outcomes. METHODS: We linked population-based data in British Columbia, Canada from 01/01/2002 to 12/31/2012 on all inpatient/outpatient visits and medications with a perinatal registry. For small-for-gestational-age (SGA) births, we assessed csDMARD exposure 90 days preconception or during pregnancy until date of delivery. For congenital anomalies, we determined csDMARD exposure 90 days preconception or during the first trimester. We used multivariable logistic regression models fitted with generalised estimating equations and calculated post-hoc power. RESULTS: There were 185 pregnancies in 175 women (31.3±5.4 years) and 6,064 pregnancies in 4,387 women (31.1±5.4 years) in the csDMARD exposed and unexposed groups, respectively. Hydroxychloroquine, azathioprine, sulfasalazine, and methotrexate exposure before or during pregnancy were not associated with SGA births. The most sufficiently powered analyses were those for hydroxychloroquine, where exposure during pregnancy resulted in an adjusted odds ratio (aOR) of 1.12 (95% confidence interval [CI], 0.65-1.94) for SGA births. Although post-hoc power calculations indicate less power to detect associations between csDMARDs and congenital anomalies, results indicate methotrexate exposure during the first trimester is associated with elevated odds for congenital anomalies (aOR 6.58, 95% CI 1.15-37.75). CONCLUSIONS: Findings are consistent with current guidelines regarding specific csDMARD use during the perinatal period for women with RD. It is important to report well-designed epidemiologic studies to facilitate future RD/csDMARD-specific meta-analyses.

Perinatal use and discontinuation of disease-modifying anti-rheumatic drugs and biologics in women with rheumatoid arthritis: a cohort study.

OBJECTIVES: To characterize the utilization and discontinuation of medications before, during and after pregnancy among women with RA. METHODS: We used population-based administrative data to identify women with RA who had a singleton pregnancy ending in delivery between 1 January 2002 and 31 December 2012. We assessed the utilization of RA medications, namely, conventional synthetic DMARDs, biologics, glucocorticosteroids and NSAIDs, across six windows spanning 24 and 12 months before the start of pregnancy, each trimester of pregnancy and 12 months post-pregnancy. We defined medication discontinuation as no prescription in a given window following a prescription in the preceding window and evaluated predictors using logistic regression models, calculating adjusted odds ratios (ORs) and 95% CIs. RESULTS: We studied 1730 pregnancies in 1301 women with RA (mean age at delivery 31.4 ± 5.4 years). We observed substantial medication discontinuation, particularly in the first trimester, with discontinuation of antimalarials in 57.3% of patients, azathioprine 59.1%, sulfasalazine 69.5% and biologics 50.8%. Factors inversely associated with discontinuation of antimalarials in the first trimester were maternal age [OR 0.90 (95% CI 0.86, 0.95)] and number of rheumatology visits [OR 0.86 (95% CI 0.75, 0.97)] and for biologics, prior adverse birth outcome [OR 0.22 (95% CI 0.05, 0.95)]. CONCLUSION: Our population-based study shows frequent discontinuation of medications for RA, particularly in the first trimester. Findings indicate a need to educate women with RA who are planning pregnancy on the benefits and risks of medications during pregnancy.

"r/Thritis", Pregnancy, and Parenting: A Qualitative Descriptive Study of Reddit Forums to Explore Information Needs and Concerns of Women With Rheumatoid Arthritis.

OBJECTIVE: Rheumatoid arthritis (RA) disproportionately affects more women than men, often striking during childbearing years. Because the Internet, particularly social media, is increasingly used by patients with chronic conditions seeking and sharing information, our objective was to conduct a qualitative descriptive study of threads on the social news website, Reddit, to understand the information needs and concerns of women with RA regarding pregnancy and parenting. METHODS: We searched threads (original posts and responses) on three subreddit sites, "r/Thritis," "r/Rheumatoid," and "r/BabyBumps," over a 10-year period between October 27, 2008, and October 27, 2018. All threads were reviewed, and those that specifically mentioned having RA and fertility/family planning, pregnancy/reproduction, and/or parenting/having children were included. We applied a thematic analysis to the threads, which involved initial line-by-line coding, clustering of codes into subcategories and categories, and abstraction into final themes. RESULTS: We identified 87 threads and included 59 for qualitative analysis. The thematic analysis led to the identification of five themes. Theme one (finding a community) captures motivations for seeking information online. Themes two (making decisions about pregnancy and having children) and three (worrying about the impacts of arthritis on pregnancy and parenting) capture women's concerns and thought processes. Themes four (information needs for managing arthritis throughout the perinatal period) and five (pregnancy information and resources for women with arthritis) describe the community's specific informational needs. CONCLUSION: A qualitative analysis of publicly available threads about the relationship between RA and issues of pregnancy and parenting identified areas of concern and further information need. These forums also provided an online community where women with RA sought social support and encouragement. Altogether, findings speak to the importance of supporting the information and care needs of women with RA who are pregnant or considering pregnancy.

Risk of congenital anomalies in infants born to women with autoimmune disease using biologics before or during pregnancy: a population-based cohort study.

OBJECTIVES: To determine the association between perinatal biologic use and congenital anomalies in women with autoimmune disease. METHODS: We linked population-based administrative health data including information on all medications with a perinatal registry in British Columbia, Canada. Women with one or more autoimmune diseases who had pregnancies between January 1st, 2002 and December 31st, 2012 were included. Exposure to biologics was defined as having at least one biologic prescription 3 months before conception or during the first trimester of pregnancy. Each exposed pregnancy was matched with five unexposed pregnancies using high dimensional propensity scores (HDPS). Logistic regression modelling was used to evaluate the association between biologics use and congenital anomalies. RESULTS: The HDPS-matched cohort included 117 pregnancies (107 women) exposed to biologics, and 585 pregnancies (562 women) that were not exposed to biologics during the period of interest; 6% of newborns had ≥1 congenital anomalies at birth, in the exposed and unexposed groups. There were no obvious patterns with regards to the congenital anomalies observed in the biologics exposed group. In primary analysis, the OR for the association between biologic exposure and congenital anomalies was 1.06 (95%CI 0.46-2.47). Secondary and sensitivity analyses did not change the results appreciably. CONCLUSIONS: These population-based data suggest that the use of biologics before and during pregnancy is not associated with an increased risk of congenital anomalies.

Concurrent inflammatory myopathy and myasthenia gravis with or without thymic pathology: A case series and literature review.

OBJECTIVES: The association of myasthenia gravis (MG) and inflammatory myositis (IM) is rare and typically only one of the diseases is present. The management of the 2 diseases differs, therefore it is important to recognize the concomitant presentation. Here, we report a case series of 7 patients with co-existing MG and IM with review of the literature. METHOD: We identified 7 patients with concurrent MG and IM who were followed at the Neuromuscular Disease Program at a tertiary referral center in Vancouver, British Columbia from 2004 to 2017. RESULT: All 7 patients had ocular or bulbar involvement as manifestation of MG. Three patients had simultaneous onset of MG and IM, 2 of whom presented with myasthenia crisis and fulminant myositis. In the other 4 patients, MG was the initial presentation and IM occurred 3-11 years after MG. Among these 7 patients, 4 had underlying thymic pathology, including 2 with benign thymoma and 2 with stage IV thymoma; all 4 patients had antibodies to acetylcholine receptor (AChR). Of the 3 patients with no thymic pathology by imaging or histology, 2 had positive AChR antibody titer. For treatment, the thymoma was resected and chemotherapy was administered if appropriate. Additional immunosuppressive therapies including high-dose glucocorticoid, intravenous immunoglobulin (IVIG), methotrexate, mycophenolate, or cyclosporine were necessary to achieve remission. Two patients with no thymoma had refractory MG and IM, and both responded to rituximab. We also conducted a literature review on the clinical characteristics and management of this condition, and compared the previously reported cases to the patients in our series. CONCLUSION: This is one of the largest case series of MG-IM overlap with or without thymic pathology. In this cohort, the 2 disease entities can occur simultaneously, or one presents before the other. Most of the patients responded well to steroid, acetylcholinesterase inhibitor, and immunosuppressive agents. In very refractory cases, rituximab appeared to be effective, which has not been reported for the treatment of this condition before.

Phylogeny and taxonomic synopsis of PoasubgenusPseudopoa (including Eremopoa and Lindbergella) (Poaceae, Poeae, Poinae).

Eremopoa is a small genus of annual grasses distributed from Egypt to western China. Phylogenetic analyses of plastid and nuclear ribosomal DNA show that Eremopoa species, together with the monotypic genus Lindbergella and a single species of Poa (P.speluncarum), are nested within the genus Poa, in a clade that we accept as Poasubg.Pseudopoa. Here we accept seven species, four subspecies and four varieties in Poasubg.Pseudopoa. Five new combinations are made: Poaattalica, P.diaphora var. alpina, P.diaphora var. songarica, P.nephelochloides and P.persicasubsp.multiradiata; P.millii is proposed as a replacement name for E.capillaris; and Poa sections Lindbergella and Speluncarae are proposed. We provide a diagnosis for Poasubg.Pseudopoa, synonymy for and a key to the taxa. Eight lectotypes are designated: Eragrostisbarbeyi Post, Eremopoanephelochloides Roshev., Glyceriataurica Steud., Nephelochloatripolitana Boiss. & Blanche, Poacilicensis Hance, Poaparadoxa Kar. & Kir., Poapersicavar.alpina Boiss and Poapersicasubsp.cypria Sam. Eremopoamedica is re-identified as a species of Puccinellia.

Risk of Myocardial Infarction and Stroke in Patients With Granulomatosis With Polyangiitis (Wegener's): A Population-Based Study.

OBJECTIVE: To assess the relative risk of myocardial infarction (MI) and ischemic stroke in patients with newly diagnosed granulomatosis with polyangiitis (Wegener's) (GPA) compared with that in controls from the general population. METHODS: Using a population-based database from the province of British Columbia, Canada, we conducted a matched cohort study in which each patient with incident GPA was matched for age, sex, and entry time with up to 10 individuals from the general population. Patients in the GPA cohort were required to have received at least 1 prescription for oral glucocorticoids, methotrexate, cyclophosphamide, leflunomide, azathioprine, cyclosporine, mycophenolate mofetil, or rituximab within 1 month before or 6 months after the index date. We compared the incidence rates of MI and ischemic stroke between the 2 groups and calculated hazard ratios (HRs), adjusting for confounders. RESULTS: Among 504 patients with incident GPA (53.4% female, mean age 57.4 years), MI developed in 23 patients, and ischemic stroke developed in 18 patients (incidence rates of 11.7 per 1,000 person-years and 8.9 per 1,000 person-years, respectively). The incidence rates among 5,222 subjects without GPA were 5.2 per 1,000 person-years and 4.3 per 1,000 person-years, respectively. The multivariable HRs among GPA patients were 1.86 (95% confidence interval [95% CI] 1.05-3.31) for MI and 1.50 (95% CI 0.78-2.89) for ischemic stroke. The age-, sex-, and entry time-matched HR for cardiovascular disease (composite outcome of MI or stroke) was highest during the first year after GPA diagnosis (HR 2.88, 95% CI 1.37-6.08). CONCLUSION: Patients with GPA have a significantly increased risk of MI and a non-statistically significant trend toward an increased risk of ischemic stroke. Monitoring for this complication and vigilance in modifying risk factors are particularly warranted in this patient population, especially early after the diagnosis of GPA.

Increased risk of cardiovascular disease in giant cell arteritis: a general population-based study.

OBJECTIVE: To determine the risk of newly recorded myocardial infarction (MI) and stroke among incident GCA cases compared with controls from the general population. We also evaluated time trends during follow-up. METHODS: We conducted a matched cohort study (1996-2010) of all patients with incident GCA from the province of British Columbia, Canada. We estimated incidence rates of MI and stroke according to GCA disease duration. We calculated hazard ratios (HRs), adjusting for potential confounders. RESULTS: Among 809 individuals with GCA (mean age 75.9 years, 75.8% female), 83 developed MI and 60 developed stroke, with corresponding incidence rates of 38.1 and 26.4/1000 person-years, respectively. Compared with non-GCA cases, the age-, sex- and entry time-matched HRs were 2.75 (95% CI 2.16, 3.50) for MI and 2.21 (95% CI 1.68, 2.91) for stroke. When other covariates were adjusted for, the corresponding HRs were 1.77 (95% CI 1.29, 2.43) and 2.04 (95% CI 1.43, 2.93). The age-, sex- and entry time-matched HRs for MI and stroke were highest during the first year after GCA diagnosis [4.76 (95% CI 3.29, 6.88) and 3.20 (95% CI 2.11, 4.87), respectively]. CONCLUSION: These findings provide general population-based evidence that GCA patients are at a substantially increased risk of cardiovascular disease. Increased monitoring for this potentially fatal outcome and its modifiable risk factors is warranted for GCA patients.

Multipronged strategy to reduce routine-priority blood testing in intensive care unit patients.

PURPOSE: The purpose of the study is to reduce unnecessary ordering of routine-priority blood tests. METHODS: In this before-after study, we studied all patients admitted to a 15-bed tertiary intensive care unit (ICU) from July 1, 2011, to June 27, 2013. Based on input from intensivists, acceptable indications for ordering routine-priority complete blood counts (CBCs) and electrolyte/renal panels were developed. Sequential interventions were (1) education sessions for ICU housestaff about the lack of evidence for routine-priority blood tests; (2) an item on the ICU rounds checklist to ask if routine-priority blood tests were indicated; (3) a rubber stamp, "routine bloodwork NOT indicated for tomorrow," was used in the chart; (4) a prompt in the electronic ordering system to allow only accepted indications; and (5) a second educational session for ICU housestaff. We measured numbers of tests done before and after these interventions. RESULTS: After introduction of interventions, there were 0.14 fewer routine-priority CBCs and 0.13 fewer routine-priority electrolyte/renal panels done per patient-day. Nonroutine CBCs and nonroutine electrolyte/renal panels increased by 0.03 and 0.02 tests per patient-day, respectively. This overall reduction in tests equates to an adjusted savings of $11,200.24 over 1 year in 1 ICU. There were no differences in demographics, severity of illness, length of stay, or number of red cell transfusions between the 2 periods. CONCLUSION: Sequential interventions to discourage the ordering of routine-priority blood tests in an ICU were associated with a significant decrease in the number of tests ordered.

The risk of deep venous thrombosis and pulmonary embolism in giant cell arteritis: a general population-based study.

IMPORTANCE: Patients with giant cell arteritis (GCA) may have an increased risk of pulmonary embolism (PE), similar to other systemic vasculitidies; however, no relevant population data are available to date. OBJECTIVE: To evaluate the future risk and time trends of new venous thromboembolism (VTE) in individuals with incident GCA at the general population level. DESIGN: Observational cohort study. SETTING: General population of British Columbia. PARTICIPANTS: 909 patients with incident GCA and 9288 age-matched, sex-matched and entry-time-matched control patients without a history of VTE. MAIN OUTCOME MEASURES: We calculated incidence rate ratios (IRR) overall, and stratified by GCA duration. We calculated HR of PE and deep vein thrombosis (DVT), adjusting for potential VTE risk factors. RESULTS: Among 909 individuals with GCA (mean age 76 years, 73% women), 18 developed PE and 20 developed DVT. Incidence rates (IR) of VTE, PE and DVT were 13.3, 7.7 and 8.5 per 1000 person-years (PY) in GCA cohort, versus 3.7, 1.9 and 2.2 per 1000 PY in the comparison cohort. The corresponding IRRs (95% CI) for VTE, PE and DVT were 3.58 (2.33 to 5.34), 3.98 (2.22 to 6.81) and 3.82 (2.21 to 6.34) with the highest IRR observed in the first year of GCA diagnosis (7.03, 7.23 and 7.85, respectively). Corresponding fully adjusted HRs (95% CI) were 2.49 (1.45 to 4.30), 2.71 (1.32 to 5.56) and 2.78 (1.39 to 5.54). CONCLUSIONS AND SIGNIFICANCE: These findings provide general population-based evidence that patients with GCA have an increased risk of VTE, calling for increased vigilance in preventing this serious, but preventable complication, especially within months after GCA diagnosis.

Mass-gathering medicine: creation of an online event and patient registry.

UNLABELLED: INTRODUCTION/PROBLEM: A review of the mass-gathering medicine literature confirms that the research community currently lacks a standardized approach to data collection and reporting in relation to large-scale community events. This lack of consistency, particularly with regard to event characteristics, patient characteristics, acuity determination, and reporting of illness and injury rates makes comparisons between and across events difficult. In addition, a lack of access to good data across events makes planning medical support on-site, for transport, and at receiving hospitals, challenging. This report describes the development of an Internet-hosted, secure registry for event and patient data in relation to mass gatherings. METHODS: Descriptive; development and pilot testing of a Web-based event and patient registry. RESULTS: Several iterations of the registry have resulted in a cross-event platform for standardized data collection at a variety of events. Registry and reporting field descriptions, successes, and challenges are discussed based on pilot testing and early implementation over two years of event enrollment. CONCLUSION: The Mass-Gathering Medicine Event and Patient Registry provides an effective tool for recording and reporting both event and patient-related variables in the context of mass-gathering events. Standardizing data collection will serve researchers and policy makers well. The structure of the database permits numerous queries to be written to generate standardized reports of similar and dissimilar events, which supports hypothesis generation and the development of theoretical foundations in mass-gathering medicine.

Acceptance of a rapid herpes test in labour: survey of attitudes of patients and health care providers.

OBJECTIVE: To determine the acceptability to pregnant women and their health care providers of a rapid test for genital herpes simplex virus (HSV) in labour. METHODS: A cross-sectional survey was conducted with outpatient pregnant women and their health care providers (obstetricians, family physicians and midwives) at BC Women's Hospital and Health Centre. RESULTS: Of pregnant women approached, 207 (92%) completed the survey; 90% reported no history of genital herpes. Rapid HSV testing in labour was acceptable to 85% of pregnant women. Among the 133 women who were planning a vaginal delivery, 63% were willing to consider delivery by Caesarean section and 53% were willing to consider intrapartum anti-viral medications if HSV was present in the genital tract. Of 51 health care providers surveyed, 98% indicated interest in knowing if their patient had a newly acquired HSV infection, while 84% indicated interest in knowing if the patient had a reactivation of infection. If HSV was detected in their patient's genital tract, 36% indicated they would recommend a Caesarean section, and 25% would consider antiviral medication as an investigational intrapartum treatment. Interestingly, both of these proportions increased if the patient had ruptured membranes for more than four hours. CONCLUSION: Most pregnant women and their health care providers are receptive to the use of a rapid polymerase chain reaction test to detect genital HSV shedding in labour. This supports the development of HSV rapid testing and antiviral therapy trials in the labour setting.

The evaluation of the fetal fibronectin test for prediction of preterm delivery in symptomatic patients.

OBJECTIVE: This study was conducted to evaluate the usefulness of testing for fetal fibronectin (fFN) to rule out the diagnosis of preterm labour in symptomatic patients in a Canadian setting. METHODS: This was a prospective, blinded clinical evaluation of fFN testing in women presenting with threatened preterm labour at between 24 and 34 weeks' gestation at two Canadian tertiary care centres. RESULTS: Of the 149 women tested, 32 had a positive fFN test. In the total patient population, 10.1% delivered within seven days of testing, and 18.2% delivered prior to 34 weeks. A negative fFN result was associated with a 97.4% likelihood of delivering more than seven days after testing and with a 91.4% chance of delivering after 34 weeks. CONCLUSION: The fFN test appears to provide useful information in the risk assessment of Canadian women presenting with symptoms compatible with preterm labour. A negative test has a high predictive value for delivering more than seven days after presentation.