Development and validation of the Cannabis Exposure in Pregnancy Tool (CEPT): a mixed methods study.

BACKGROUND: Evidence of associations between prenatal cannabis use (PCU) and maternal and infant health outcomes remains conflicting amid broad legalization of cannabis across Canada and 40 American states. A critical limitation of existing evidence lies in the non-standardized and crude measurement of prenatal cannabis use (PCU), resulting in high risk of misclassification bias. We developed a standardized tool to comprehensively measure prenatal cannabis use in pregnant populations for research purposes. METHODS: We conducted a mixed-methods, patient-oriented tool development and validation study, using a bias-minimizing process. Following an environmental scan and critical appraisal of existing prenatal substance use tools, we recruited pregnant participants via targeted social media advertising and obstetric clinics in Alberta, Canada. We conducted individual in-depth interviews and cognitive interviewing in separate sub-samples, to develop and refine our tool. We assessed convergent and discriminant validity internal consistency and 3-month test-retest reliability, and validated the tool externally against urine-THC bioassays. RESULTS: Two hundred fifty four pregnant women participated. The 9-item Cannabis Exposure in Pregnancy Tool (CEPT) had excellent discriminant (Cohen's kappa = -0.27-0.15) and convergent (Cohen's kappa = 0.72-1.0) validity; as well as high internal consistency (Chronbach's alpha = 0.92), and very good test-retest reliability (weighted Kappa = 0.92, 95% C.I. [0.86-0.97]). The CEPT is valid against urine THC bioassay (sensitivity = 100%, specificity = 82%). CONCLUSION: The CEPT is a novel, valid and reliable measure of frequency, timing, dose, and mode of PCU, in a contemporary sample of pregnant women. Using CEPT (compared to non-standardized tools) can improve measurement accuracy, and thus the quality of research examining PCU and maternal and child health outcomes.

Nutrition Interventions for Lowering Cardiovascular Risk After Hypertensive Disorders of Pregnancy: A Systematic Review.

Background: Hypertension is one of the most common medical problems during pregnancy. Hypertensive disorders of pregnancy (HDP) increase the risk of premature cardiovascular disease (CVD) 2- to 4-fold within 10 years after delivery. Early health behaviour modifications may prevent or manage several cardiovascular risk factors. Importantly, compared with women without HDP, fewer women with HDP achieve national dietary guidelines to prevent CVD. This highlights an opportunity for programs tailored for women post-HDP to support their nutritional behaviours as a key component of postpartum CVD preventive care. This systematic review investigated the impacts of nutrition modifications on lowering measures of CVD risk after HDP. Methods: Four electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library) were searched in October 2022 with a search strategy focused on nutrition programs/interventions and women post-HDP. Additional inclusion criteria were original research and reported outcome of CVD risk or cardiovascular risk factors. Results: Six studies were included: 4 experimental trials and 2 prospective cohort studies. Of the nutrition interventions, 4 were embedded within comprehensive health behaviour intervention programs. Outcome measures varied, but all studies reported blood pressure. A narrative synthesis found that the range of changes in blood pressure varied from no change to clinically meaningful change. Conclusions: This review found statistically nonsignificant yet clinically important improvements in measures of cardiovascular risk across a range of nutritional interventions in women after HDP. Further high-quality evidence is needed to inform the design and implementation of nutritional preventive cardiovascular care targeting this high CVD-risk population.

Contexte: L'hypertension est l'un des problèmes médicaux les plus fréquents durant la grossesse. Les troubles hypertensifs de la grossesse (THG) font augmenter le risque de maladies cardiovasculaires (MCV) prématurées de 2 à 4 fois dans les 10 années après l'accouchement. Des modifications précoces des comportements liés à la santé peuvent permettre de prévenir ou de prendre en charge plusieurs facteurs de risque cardiovasculaire. Notamment, par rapport aux femmes sans THG, moins de femmes atteintes de THG se conforment aux lignes directrices nationales en matière d'alimentation pour prévenir les MCV. D'où la possibilité qui s'offre aux programmes adaptés aux femmes post-THG d'encourager l'adoption de leurs comportements nutritionnels, une composante essentielle des soins de prévention des MCV dans la période du post-partum. La présente revue systématique visait à examiner les répercussions des modifications nutritionnelles sur la réduction des mesures du risque de MCV après les THG. Méthodes: En octobre 2022, nous avons effectué des recherches dans 4 bases de données électroniques (MEDLINE, Embase, CINAHL, Cochrane Library) au moyen d'une stratégie de recherche axée sur les interventions/programmes nutritionnels et les femmes post-THG. Les critères d'inclusion supplémentaires étaient la recherche initiale et les résultats signalés du risque de MCV ou des facteurs de risque cardiovasculaire. Résultats: Nous avons tenu compte de 6 études : 4 essais expérimentaux et 2 études de cohorte prospectives. Parmi les interventions nutritionnelles, 4 étaient intégrées aux programmes exhaustifs d'interventions sur les comportements liés à la santé. Les critères de jugement variaient, mais la pression artérielle était signalée dans toutes les études. Une synthèse narrative a permis de constater que l'étendue des changements dans la pression artérielle allait d'une absence de changement à des changements significatifs sur le plan clinique. Conclusions: Cette revue a permis de constater des améliorations non significatives sur le plan statistique, mais importantes sur le plan clinique des mesures du risque cardiovasculaire de différentes interventions nutritionnelles chez les femmes après les THG. D'autres données probantes de grande qualité sont nécessaires pour faciliter l'élaboration et la mise en œuvre de soins de prévention nutritionnelle des maladies cardiovasculaires visant cette population exposée à un risque élevé de MCV.

Impact of Asthma Medications During Pregnancy on Asthma Exacerbation, Maternal, and Neonatal Outcomes.

BACKGROUND: Asthma affects 5% to 13% of pregnant women, and many require daily pharmacotherapy to achieve asthma control; however, adherence to medication during pregnancy often decreases. OBJECTIVE: To understand the association between the use of or adherence to asthma medication with asthma exacerbation and maternal/neonatal outcomes. METHODS: Using linked population-based administrative databases from Alberta, Canada (2012-2018), pregnant women with asthma were categorized based on asthma medication use 1 year before pregnancy: short-acting ß-agonists (SABA), inhaled corticosteroids (ICS), and ICS with long-acting ß-agonists (ICS+LABA). Women on ICS+LABA were grouped by trajectory of adherence during pregnancy using group-based trajectory modeling. Logistic regressions were used to estimate the associations between the use of or trajectories of adherence to asthma medication during pregnancy with asthma exacerbation and maternal/neonatal outcomes. RESULTS: Overall, 13,509 of 238,751 (5.7%) pregnant women had asthma before pregnancy (SABA: 24.7%; ICS: 12.5%; ICS+LABA: 25.1%; none: 36.1%). The use of SABA (adjusted odds ratio [aOR]: 1.79, 95% confidence interval [CI]: 1.21, 2.64), ICS (aOR: 3.37, 95% CI: 2.10, 5.39), and ICS+LABA (aOR: 3.64, 95% CI: 2.57, 5.17) had greater odds of disease exacerbation than no asthma medication during pregnancy. ICS+LABA adherence groups during pregnancy included low (79.8%), moderate-to-decreasing (14.0%), and moderate-to-increasing (6.2%). The moderate-to-decreasing (aOR: 1.45, 95% CI: 1.14, 1.84) and moderate-to-increasing (aOR: 2.06, 95% CI: 1.50, 2.83) adherence groups had greater odds of disease exacerbation than the low adherence group. ICS use during pregnancy decreased odds of preterm birth (aOR: 0.62; 95% CI: 0.39, 0.99) and neonatal intensive care unit admission (aOR: 0.66; 95% CI: 0.45, 0.97). Other group comparisons were not statistically significant. CONCLUSIONS: Our study shows the importance of continuing asthma maintenance medication during pregnancy to improve outcomes. Future research should study the postpartum and long-term outcomes with asthma medication during pregnancy.

Incidence of venous thromboembolism in patients with ovarian cancer receiving neoadjuvant chemotherapy: systematic review and meta-analysis.

OBJECTIVE: Venous thromboembolism is associated with significant patient morbidity, mortality, and can lead to delays in treatment for patients with cancer. The objectives of this study were to identify the incidence of venous thromboembolism in patients with advanced ovarian cancer receiving neoadjuvant chemotherapy, and identify risk factors for venous thromboembolism. METHODS: A systematic literature search of biomedical databases, including Ovid Medline, Web of Science, Scopus, CINAHL, and Embase was performed on December 6, 2022 and updated on December 21, 2023 for peer reviewed articles. Studies were included if they were cohort studies or randomized controlled trials that evaluated the incidence of venous thromboembolism for patients with ovarian cancer receiving neoadjuvant chemotherapy. Risk of bias assessment was performed using the Newcastle Ottawa Scale for cohort studies and the Cochrane risk of bias tool for randomized controlled trials. Random effects meta-analysis was used to pool results across studies. RESULTS: A total of 2636 studies were screened, and 11 were included in the review. Ten were retrospective cohort studies, and one was a randomized controlled trial. The incidence of venous thromboembolism in the included studies ranged from 0% to 18.9%. The pooled incidence rate of venous thromboembolism was 10% (95% confidence interval (CI) 7% to 13%). This remained significant when restricted to only studies with a low risk of bias (pooled incidence of 11%, 95% CI 9% to 14%). Body mass index of ≥30 kg/m2 was a significant risk factor for venous thromboembolism with a pooled odds ratio of 1.76 (95% CI 1.13 to 2.76) CONCLUSIONS: The results from this study demonstrated a 10% incidence of venous thromboembolism for patients with advanced ovarian cancer receiving neoadjuvant chemotherapy. This suggests that there may be a role for universal thromboprophylaxis in this population. TRIAL REGISTRATION: PROSPERO CRD42022339602.

Publicly funded healthcare costs associated with orofacial clefts for children born in Alberta, Canada between 2002 and 2018.

BACKGROUND: Orofacial clefts (OFCs) include cleft palate (CP), cleft lip (CL), and cleft lip with cleft palate (CLP) and require multidisciplinary healthcare services. Alberta, Canada has a publicly funded, universal access healthcare system. This study determined publicly funded healthcare costs for children with an OFC and compared these costs to children without congenital anomalies. METHODS: This retrospective population-based cohort analysis used the Alberta Congenital Anomalies Surveillance System to identify children born between 2002 and 2018 with an isolated OFC. They were matched 1:1 to a reference cohort based on sex and year of birth. The study population included 1614 children, from birth to 17 years of age linked to administrative databases to estimate annual inpatient and outpatient costs. Average annual all-cause costs were compared using two-sample independent t tests. RESULTS: The mean total cleft-related costs per patient were highest for children with CLP ($74,138 CAD, standard deviation (SD) $43,447 CAD), followed by CP ($53,062 CAD, SD $74,366 CAD), and CL ($35,288 CAD, SD $49,720 CAD). The mean total all-cause costs per child were statistically significantly higher (p < .001) in children with an OFC ($56,305 CAD, SD $57,744 CAD) compared to children without a congenital anomaly ($18,600 CAD, SD $61,300 CAD). CONCLUSIONS: Despite public health strategies to mitigate risk factors, the trend for OFCs has remained stable in Alberta, Canada for over 20 years. The costs reported are useful to other jurisdictions for comparison, and to families, healthcare professionals, service planners, and policy makers.

Exclusion of pregnant and lactating persons from breast cancer clinical trials: a review of active trials registered on ClinicalTrials.gov.

INTRODUCTION: Treatment of pregnancy-associated breast cancer is complex, as providers try to balance risks to the pregnant person and the developing fetus. Given increased case fatality and increasing incidence, there is a pressing need understand the efficacy and safety of different treatment regimens in this population; however, pregnant and lactating people have traditionally been excluded from participating in randomized controlled trials (RCTs). Given recent efforts to expand the inclusion criteria for oncology RCTs, this study aimed to review the inclusion/exclusion criteria of current breast cancer RCTs to assess what proportion of trials permitted enrollment of pregnant and lactating persons. MATERIAL AND METHODS: We conducted a comprehensive search of ClinicalTrials.gov in January 2022 to identify interventional studies of breast cancer in adults that were actively recruiting. The primary outcomes were the exclusion of pregnant and lactating people. RESULTS: The search identified 1706 studies, of which 1451 met eligibility criteria. Overall, 69.4% and 54.8% of studies excluded pregnant and lactating people, respectively. The exclusion of pregnant and lactating persons differed by study characteristics but extended across all trial designs, locations, phases and interventions. Exclusion of pregnant and lactating persons was most common in trials where the intervention was biological (86.3%), drug (83.5%) or radiation (81.5%). CONCLUSIONS: The exclusion of pregnant and lactating people from clinical trials contributes to evidence gaps in how to treat this population. A paradigm shift is needed that focuses on how research can be used to protect pregnant people from future harms, instead of protecting pregnant people from research-related risks.

Implementation of Multiple Marker Screening for Preterm Preeclampsia in a Single Tertiary Obstetric Centre.

OBJECTIVES: Early assessment of pregnant individuals for risk of preterm preeclampsia (PE) is possible at the 11-14 week ultrasound visit using a validated multiple marker algorithm, allowing timely use of preventative low-dose acetylsalicylic acid (LDA) in high-risk patients. With no established early screening program for preterm PE in Canada, our objectives were to assess the acceptability and operational impact of routine screening for preterm PE during the 11-14 week ultrasound visit, evaluate uptake and adherence to LDA when recommended, and assess screening performance. METHODS: A prospective implementation study of preterm PE screening among pregnant patients at the ultrasound unit of a tertiary obstetric centre in Toronto, Canada. RESULTS: A total of 1057 patients were screened, with an acceptance rate of 87.1%. First-trimester ultrasound appointment time increased by a median time of 7 minutes (Interquartile range 6-9). By 16 weeks gestation, 88.7% of high-risk patients had started LDA, with adherence of 88.7%‒94.6% from 16‒36 weeks. Satisfaction with counselling was ≥7/10 in more than 95% of patients. There were 7 cases of preterm PE (0.73%), 3 in the low-risk group (0.35%), and 4 in the high-risk group (4.1%). When accounting for LDA use, the treatment-adjusted detection rate was 78.6%. CONCLUSIONS: We demonstrate successful implementation of a validated, effective screening and prevention program for preterm PE as a first step in the implementation of a broader program adaptable for cultural, access/equity considerations, and marker availability.

Early childhood trajectories of domain-specific developmental delay and gestational age at birth: An analysis of the All Our Families cohort.

OBJECTIVE: To describe developmental domain-specific trajectories from ages 1 through 5 years and to estimate the association of trajectory group membership with gestational age for children born between ≥34 and <41 weeks gestation. METHODS: Using data from the All Our Families cohort, trajectories of the domain-specific Ages & Stages Questionnaire scores were identified and described using group-based trajectory modeling for children born ≥34 and <41 weeks of gestation (n = 2664). The trajectory groups association with gestational age was estimated using multinomial logistic regression. RESULTS: Across the five domains, 4-5 trajectory groups were identified, and most children experienced changing levels of risk for delay over time. Decreasing gestational age increases the Relative risk of delays in fine motor (emerging high risk: 1.46, 95% CI: 1.19-1.80; resolving moderate risk: 1.11, 95% CI: 1.03-1.21) and gross motor (resolving high risk: 1.21, 95% CI: 1.04-1.42; and consistent high risk: 1.64, 95% CI: 1.20-2.24) and problem solving (consistent high risk: 1.58 (1.09-2.28) trajectory groups compared to the consistent low risk trajectory groups. CONCLUSION: This study highlights the importance of longitudinal analysis in understanding developmental processes; most children experienced changing levels of risk of domain-specific delay over time instead of having a consistent low risk pattern. Gestational age had differential effects on the individual developmental domains after adjustment for social, demographic and health factors, indicating a potential role of these factors on trajectory group membership.

Thiopurine Exposure During Pregnancy is Not Associated With Anemia in Infants Born to Mothers With IBD.

Background: Thiopurines are commonly used to treat inflammatory bowel disease (IBD). Thiopurines are considered safe throughout pregnancy. However, a published study suggested the risk of neonatal anemia was increased if exposed to thiopurines in utero. This prospective cohort study aimed to determine if there is an increased risk of cytopenia among infants born to pregnant people with IBD, exposed or unexposed to thiopurines, compared to infants born to those without IBD. Methods: Pregnant IBD patients, with and without thiopurine exposure, and one cohort of control individuals were recruited over a 5-year period. Consenting individuals completed a questionnaire and infants had a complete blood cell count at the newborn heel prick. Anemia was defined as hemoglobin (Hb) < 140g/L. Descriptive statistics were used to characterize the study population. Fisher exact tests were used to examine differences in outcomes between groups, a P-value of < 0.05 was deemed significant. Results: Three cohorts were recruited: 19 IBD patients on thiopurines, 50 IBD patients not on thiopurines, and 37 controls (total of 106). Neonatal median Hb was not different with 177g/L (IQR 38g/L) for the IBD thiopurine group, 180.5g/L (IQR 40g/L) for the IBD non-thiopurine group, and 181g/L (IQR 37g/L) for the controls. Nineteen infants (18%) were cytopenic with 12 (11%) anemic, 6 (5.6%) thrombocytopenic, and 1 (0.94%) lymphopenic. Thiopurine exposure was only in one, mildly anemic, infant. Conclusions: These findings further support physicians and IBD patients contemplating pregnancy that current guidelines recommending thiopurine adherence do not lead to increased perinatal risk of anemia or cytopenia.

Bilateral salpingo-oophorectomy at the time of benign hysterectomy among females with disabilities: a population-based cross-sectional study.

BACKGROUND: Up to 40% of patients aged ≤55 years undergo concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy, with practice variation in bilateral salpingo-oophorectomy occurring along the lines of patient health and social factors. Disability is common in premenopausal women and is an important determinant of reproductive health more broadly; however, studies on bilateral salpingo-oophorectomy rates among women with disabilities are lacking. OBJECTIVE: This study aimed to examine whether the use of concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy differs by preexisting disability status in adult females aged ≤55 years. STUDY DESIGN: This population-based cross-sectional study used data from the 2016-2019 US National Inpatient Sample. Females undergoing inpatient hysterectomy for a benign gynecologic indication (n=74,315) were classified as having physical (6.1%), sensory (0.1%), intellectual or developmental (0.2%), or multiple (0.2%) disabilities and compared with those without a disability. Logistic regression was used to estimate risk ratios for differences in bilateral salpingo-oophorectomy rates by disability status, adjusted for patient and clinical factors. Models were stratified by potentially avoidable or potentially appropriate bilateral salpingo-oophorectomy based on the presence of clinical indications for ovarian removal and by age group. RESULTS: Bilateral salpingo-oophorectomy at the time of benign hysterectomy occurred in 26.0% of females without a disability, with rates clearly elevated in those with a physical (33.2%; adjusted risk ratio, 1.10; 95% confidence interval, 1.05-1.14) or intellectual or developmental (31.1%; adjusted risk ratio, 1.32; 95% confidence interval, 1.02-1.64) disability, possibly elevated in those with multiple disabilities (38.2%; adjusted risk ratio, 1.20; 95% confidence interval, 0.94-1.45), and similar in those with a sensory disability (31.2%; adjusted risk ratio, 0.98; 95% confidence interval, 0.83-1.13). The results were similar but with lower statistical precision for potentially avoidable and potentially appropriate bilateral salpingo-oophorectomy, which occurred in 9.1% and 17.0% of females without a disability, respectively. The largest differences in bilateral salpingo-oophorectomy rates among women with any disability were observed in the perimenopausal 45- to 49-year age group. CONCLUSION: Females with disabilities experienced elevated concomitant bilateral salpingo-oophorectomy rates at the time of benign hysterectomy, particularly those with an intellectual or developmental disability and those of perimenopausal age, although some estimates were imprecise. Equity-focused physician training in surgical counseling and research into the epidemiology and experiences of gynecologic conditions among females with a disability may be beneficial.

The effect of geographic location and payor type on provincial-wide delivery of the GLA:D program for hip and knee osteoarthritis in Alberta, Canada.

Objective: The Good Life with osteoArthritis: Denmark (GLA:D™) program for knee and hip osteoarthritis has been shown to be effective, but evaluations have yet to explore whether effectiveness differs by program context. The present study explores whether there are differences in effectiveness of the GLA:D™ program for treatment of hip and knee osteoarthritis across program location (i.e., rural, urban, metro) and program payor (i.e., public, private) within Alberta, Canada. Design: The study population was adults with hip or knee osteoarthritis attending the 8-week GLA:D™ supervised exercise and education programme in Alberta between Sep 2017-Mar 2020. Outcomes of interest were joint-related pain and quality of life (HOOS/KOOS), health quality of life (EQ-5D-5L), and performance-based functional (30-s chair stand test; 40-m walk test) measures. Minimally clinically important changes were calculated for each outcome and ANOVA and chi-square tests were used to determine statistical significance by program location or payor. Results: Of the 1321 eligible participants, 974 (73.7%) completed the baseline questionnaire, about 50% of participants participated in a metro area and 60% paid privately for the program. There were no statistically significant differences in improvements of joint-related pain, joint-related quality of life, health-related quality of life, or performance-based functional measures by program location or program payor, except for participants who received the program in a publicly covered primary care clinic who experienced significantly larger improvements in joint-related pain. Conclusion: The implementation of the GLA:D™ program for the treatment of knee and hip osteoarthritis in Alberta is effective across a range of contexts.

Despite Increased Disease Activity, Women who Attended a Dedicated Inflammatory Bowel Disease and Pregnancy Clinic Had Infants With Higher Apgar Scores: A Population-Based Study.

BACKGROUND: Attendance at a subspecialty pregnancy clinic for women with inflammatory bowel disease (IBD) improves disease-specific pregnancy knowledge. We examined the impact of attendance at a dedicated IBD-pregnancy clinic on IBD and perinatal outcomes. METHODS: Using linked administrative databases in Alberta, Canada (2012-2019), we identified 1061 pregnant women with IBD who delivered singleton liveborn infants in-hospital who did (n = 314) and did not attend (n = 747) the clinic. Propensity score weighted multivariable log-binomial and multinomial logistic regression models were used to determine the risk of IBD and perinatal outcomes. RESULTS: The median number of clinic visits was 3 (Q1-Q3, 3-5), with 34.7% completing a preconception consultation. A greater proportion of women who attended lived near the clinic, were nulliparous, had a disease flare prior to pregnancy, and were on maintenance IBD medication (P < .05). Women who attended had increased risks of a disease flare during pregnancy (adjusted risk ratio [aRR], 2.02; 95% CI, 1.45-2.82), an IBD-related emergency department visit during pregnancy (aRR, 2.66; 95% CI, 1.92-3.68), and cesarean delivery (aRR, 1.78; 95% CI, 1.23-2.57). Despite this, clinic attendees had a decreased risk of delivering an infant with a low Apgar score at 1 minute (risk ratio [RR], 0.49; 95% CI, 0.32-0.76) and 5 minutes (RR, 0.32; 95% CI, 0.12-0.87). CONCLUSIONS: Women who attended a dedicated IBD-pregnancy clinic were more likely to have a disease flare prior to pregnancy, reflecting a more severe disease phenotype, but had similar perinatal outcomes and infants with better Apgar scores at birth. Our study suggests the value of these subspecialty clinics in providing enhanced IBD-specific prenatal care.

Association of illness perceptions and exclusive breastfeeding intentions among pregnant women with chronic conditions: A community-based pregnancy cohort study.

OBJECTIVE: We examined whether changes in illness perceptions from preconception to pregnancy were associated with intentions to exclusively breastfeed to 6 months postpartum among women with chronic physical health conditions. METHODS: We analyzed self-reported cross-sectional questionnaire data collected in the third trimester from 361 women with chronic conditions enrolled in a community-based cohort study (Alberta, Canada). For individual and total illness perceptions, measured with the Brief Illness Perception Questionnaire, women were classified using change scores (preconception minus pregnancy) into one of the following groups: "worsening," "improving," or "stable" in pregnancy. Intention to exclusively breastfeed was defined as plans to provide only breast milk for the recommended first 6 months after birth. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using multivariable logistic regression modelling, with the "stable" group as the reference and controlling for demographic factors, chronic condition duration and medication, prenatal class attendance, and social support. RESULTS: Overall, 61.8% of women planned to exclusively breastfeed to 6 months. Worsened total illness perceptions (adjusted OR 0.50, 95% CI 0.30-0.82) as well as perceptions of worsened identity (i.e., degree of symptoms; adjusted OR 0.49, 95% CI 0.28-0.85) or consequences (i.e., impact on functioning; adjusted OR 0.60, 95% CI 0.34-1.06) were associated with lower odds of intending to exclusively breastfeed to 6 months. CONCLUSIONS: Women who perceive their illness experience to worsen during pregnancy are less likely to plan to exclusively breastfeed to 6 months in accordance with public health recommendations.

Association Between the Route of Administration and Formulation of Estrogen Therapy and Hypertension Risk in Postmenopausal Women: A Prospective Population-Based Study.

BACKGROUND: Hypertension is the leading global cause of cardiovascular disease and premature mortality in women. The effects of postmenopausal hormone therapy (HT) on blood pressure are uncertain but may be related to route of estrogen administration and formulation of estrogen. We sought to determine the association between route of administration and formulation of estrogen HT and hypertension risk in postmenopausal women. METHODS: Population-based cohort study with women aged ≥45 years who filled ≥2 consecutive prescriptions for estrogen-only HT, identified from linked provincial health administrative data from Alberta, Canada, between 2008 and 2019. The primary outcome, incident hypertension, was identified using standardized International Classification of Diseases, Ninth and Tenth Revision. Cox proportional hazard models were used to calculate hazard ratios (HRs) for hypertension in women using oral HT compared with nonoral HT (transdermal, vaginal, or intramuscular). RESULTS: In total, 112 240 women used an estrogen-only form of HT. Oral estrogen was associated with a higher risk of hypertension compared with both transdermal (HR, 1.14 [95% CI, 1.08-1.20]) and vaginal (HR, 1.19 [95% CI, 1.13-1.25]) estrogens. Conjugated equine estrogen was associated with an increased risk of hypertension compared with estradiol (HR, 1.08 [95% CI, 1.04-1.14]) but not estrone (HR, 1.00 [95% CI, 0.93-1.10]). Duration of estrogen exposure and cumulative dose of estrogen was positively associated with risk of hypertension. CONCLUSIONS: Oral estrogen-only HT use was associated with an increased risk of hypertension in women. In women using estrogen-only HT, nonoral estradiol at the lowest dose and for the shortest time-period is associated with the lowest risk of hypertension.

Interview With CSCI Joe Doupe Young Investigator Awardee, Dr. Amy Metcalfe.

Dr. Amy Metcalfe is an Associate Professor in the Departments of Obstetrics and Gynecology, Medicine, and Community Health Sciences at the University of Calgary. She is also the Maternal and Child Health Program Director with the Alberta Children's Hospital Research Institute. Dr. Metcalfe's training is a perinatal epidemiologist whose research broadly focuses on the management of chronic illness during pregnancy, and how events in pregnancy impact women's health and wellbeing throughout the life course. Current major projects include co-leading the P3 Cohort study (https://p3cohort.ca), a longitudinal pregnancy cohort study, and the GROWW (Guiding interdisciplinary Research On Women's and girls' health and Wellbeing) Training Program (https://www.growwprogram.com).

The REDUCED trial: a cluster randomized trial for REDucing the utilization of CEsarean delivery for dystocia.

BACKGROUND: To reduce cesarean delivery rates in nulliparous women, guidelines for diagnosing nonprogressive labor have been developed by the National Institute of Child Health and Human Development, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine. These are mainly based on data from the Consortium for Safe Labor study. The guidelines have not been tested in a clinical trial, so the efficacy and safety of this new approach is uncertain. OBJECTIVE: This study aimed to assess whether adoption of new guidelines for diagnosing nonprogressing labor would reduce cesarean delivery rates. STUDY DESIGN: We conducted a cluster randomized controlled trial of a knowledge translation program of the guidelines in 26 Canadian hospitals (13 control sites and 13 intervention sites). The sites included all intrapartum care sites in Alberta that perform cesarean delivery and deliver at least 70 nulliparous women annually. The baseline period started on January 1, 2015. The intervention was initiated at the first intervention site in January 2017. The follow-up period began at the first intervention site in February 2017 and lasted till February 2020. The primary outcome was the rate of cesarean delivery in nulliparous women with vertex presentation in labor at term. The secondary outcomes included spontaneous vaginal birth and maternal and neonatal safety. The main data source for the primary and secondary outcomes was the Alberta Perinatal Health Program database. The cesarean delivery rates were assessed using repeated measures mixed effects logistic regression applied to individual births. RESULTS: The analysis was based on 45,193 deliveries at intervention sites and 43,725 deliveries at control sites. There was no evidence of a decrease in the rate of cesarean delivery in association with the intervention (baseline-adjusted odds ratio, 0.94; 95% confidence interval [0.85-1.05]; P=.259). The rate of spontaneous vaginal delivery increased slightly (baseline-adjusted odds ratio, 1.10; 95% confidence interval, [1.01-1.18]; P=.024). We did not observe any differences in adverse maternal or neonatal outcomes. CONCLUSION: Cesarean delivery rates in nulliparous women were not reduced by the application of recent guidelines for the diagnosis of nonprogressive labor. Spontaneous vaginal delivery-a secondary outcome-was increased in the intervention group. The intervention appears to be safe.

Unplanned Extubations Requiring Reintubation in Pediatric Critical Care: An Epidemiological Study.

OBJECTIVES: Unplanned extubations are an infrequent but life-threatening adverse event in pediatric critical care. Due to the rarity of these events, previous studies have been small, limiting the generalizability of findings and the ability to detect associations. Our objectives were to describe unplanned extubations and explore predictors of unplanned extubation requiring reintubation in PICUs. DESIGN: Retrospective observational study and multilevel regression model. SETTING: PICUs participating in Virtual Pediatric Systems (LLC). PATIENTS: Patients (≤ 18 yr) who had an unplanned extubation in PICU (2012-2020). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We developed and trained a multilevel least absolute shrinkage and selection operator (LASSO) logistic regression model in the 2012-2016 sample that accounted for between-PICU variations as a random effect to predict reintubation after unplanned extubation. The remaining sample (2017-2020) was used to externally validate the model. Predictors included age, weight, sex, primary diagnosis, admission type, and readmission status. Model calibration and discriminatory performance were evaluated using Hosmer-Lemeshow goodness-of-fit (HL-GOF) and area under the receiver operating characteristic curve (AUROC), respectively. Of the 5,703 patients included, 1,661 (29.1%) required reintubation. Variables associated with increased risk of reintubation were age (< 2 yr; odds ratio [OR], 1.5; 95% CI, 1.1-1.9) and diagnosis (respiratory; OR, 1.3; 95% CI, 1.1-1.6). Scheduled admission was associated with decreased risk of reintubation (OR, 0.7; 95% CI, 0.6-0.9). With LASSO (lambda = 0.011), remaining variables were age, weight, diagnosis, and scheduled admission. The predictors resulted in AUROC of 0.59 (95% CI, 0.57-0.61); HL-GOF showed the model was well calibrated (p = 0.88). The model performed similarly in external validation (AUROC, 0.58; 95% CI, 0.56-0.61). CONCLUSIONS: Predictors associated with increased risk of reintubation included age and respiratory primary diagnosis. Including clinical factors (e.g., oxygen and ventilatory requirements at the time of unplanned extubation) in the model may increase predictive ability.

Long-term Mortality in Individuals Diagnosed With Cancer During Pregnancy or Postpartum.

Importance: Outcomes among patients with pregnancy-associated cancers (diagnosed during pregnancy or 1-year postpartum) other than breast cancer have received relatively little research attention. High-quality data from additional cancer sites are needed to inform the care of this unique group of patients. Objective: To assess mortality and survival in premenopausal women with pregnancy-associated cancers, with a particular focus on cancers other than those of the breast. Design, Setting, and Participants: This population-based retrospective cohort study included premenopausal women (aged 18-50 years) living in 3 Canadian provinces (Alberta, British Columbia, and Ontario) diagnosed with cancer between January 1, 2003, and December 31, 2016, with follow-up until December 31, 2017, or date of death. Data analysis occurred in 2021 and 2022. Exposures: Participants were categorized as being diagnosed with cancer during pregnancy (from conception to delivery), during the postpartum period (up to 1 year after delivery), or during a time that was remote from pregnancy. Main Outcomes and Measures: Outcomes were overall survival at 1 and 5 years and time from diagnosis to death due to any cause. Cox proportional hazard models were used to estimate mortality adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs), adjusting for age at cancer diagnosis, cancer stage, cancer site, and days from diagnosis to first treatment. Meta-analysis was used to pool results across all 3 provinces. Results: During the study period there were 1014, 3074, and 20 219 participants diagnosed with cancer during pregnancy, postpartum, and periods remote from pregnancy, respectively. One-year survival was similar across the 3 groups, but 5-year survival was lower among those diagnosed with cancer during pregnancy or postpartum. Overall, there was a greater risk of death due to pregnancy-associated cancer among those diagnosed during pregnancy (aHR, 1.79; 95% CI, 1.51-2.13) and postpartum (aHR, 1.49; 95% CI, 1.33-1.67); however, these results varied across cancer sites. Increased hazard of mortality was observed for breast (aHR, 2.01; 95% CI, 1.58-2.56), ovarian (aHR, 2.60; 95% CI, 1.12-6.03), and stomach (aHR, 10.37; 95% CI, 3.56-30.24) cancers diagnosed during pregnancy, and brain (aHR, 2.75; 95% CI, 1.28-5.90), breast (aHR, 1.61; 95% CI, 1.32-1.95), and melanoma (aHR, 1.84; 95% CI, 1.02-3.30) cancers diagnosed postpartum. Conclusions and Relevance: This population-based cohort study found that pregnancy-associated cancers had increased overall 5-year mortality, though not all cancer sites presented the same risk.