Delayed cord clamping in small for gestational age preterm infants.

BACKGROUND: Infants with restricted growth for age are frequently exposed to insufficient placental circulation and are more likely to develop postnatal complications. Delayed cord clamping at birth for these infants requires further exploration. OBJECTIVE: This study aimed to compare the short-term neonatal outcomes of delayed cord clamping with that of early cord clamping in small for gestational age preterm infants and to explore whether the effects of delayed cord clamping in small for gestational age preterm infants are different from that in non-small for gestational age preterm infants. STUDY DESIGN: We conducted a national retrospective cohort study, including infants born at <33 weeks' gestation and admitted to the Canadian Neonatal Network units between January 2015 and December 2017. Small for gestational age infants (birthweight of <10th percentile for gestational age and sex) who received delayed cord clamping ≥30 seconds were compared with those who received early cord clamping. In addition, non-small for gestational age infants who received delayed cord clamping were compared with those who received early cord clamping. The main study outcomes included composite outcome of mortality or major morbidity, neonatal morbidity rate, mortality rate, peak serum bilirubin, and number of blood transfusions. Multivariable logistic and linear regression models with a generalized estimation equation approach were used to account for the clustering of infants within centers. RESULTS: Overall, 9722 infants met the inclusion criteria. Of those infants, 1027 (10.6%) were small for gestational age. The median (interquartile range) gestational age was 31 weeks (range, 28-32 weeks). After adjusting for potential confounders, delayed cord clamping in small for gestational age infants was associated with a reduction in the composite outcome of mortality or major morbidity (adjusted odds ratio, 0.60; 95% confidence interval, 0.42-0.86) compared with early cord clamping. There was no difference between the 2 groups in peak serum bilirubin. Many associated benefits of delayed cord clamping in small for gestational age infants were similar to those in non-small for gestational age infants. CONCLUSION: Delayed cord clamping in small for gestational age preterm infants was associated with decreased odds of mortality or major morbidity. Many of the benefits of delayed cord clamping in the small for gestational age preterm infants were similar to those identified in the non-small for gestational age preterm infants.

Guideline No. 401: Sonographic Cervical Length in Singleton Pregnancies: Techniques and Clinical Applications.

OBJECTIVES: • To assess the association between sonography-derived cervical length measurement and preterm birth. • To describe the various techniques to measure cervical length using sonography. • To review the natural history of the short cervix. • To review the clinical uses, predictive ability, and utility of sonography-measured short cervix. OUTCOMES: Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions. INTENDED USERS: Clinicians involved in the obstetrical management or cervical imaging of patients at increased risk of a short cervix. TARGET POPULATION: Women at increased risk of a short cervix or at risk of preterm birth. EVIDENCE: Literature published up to June 2019 was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, cervical insufficiency, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date or language restrictions. Grey (unpublished) literature was identified through searching the websites of health technology assessment agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The evidence and this guideline were reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made and graded according to the rankings of the Canadian Task Force on Preventive Health Care (Online Appendix Table A1). BENEFITS, HARMS, COSTS: Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the sonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth. SUMMARY STATEMENTS (CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE GRADING IN PARENTHESES): RECOMMENDATIONS (CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE GRADING IN PARENTHESES).

No. 257-Ultrasonographic Cervical Length Assessment in Predicting Preterm Birth in Singleton Pregnancies.

OBJECTIVES: To review (1) the use of ultrasonographic-derived cervical length measurement in predicting preterm birth and (2) interventions associated with a short cervical length. OUTCOMES: Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions. EVIDENCE: Published literature was retrieved through searches of PubMed and The Cochrane Library up to December 2009, using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, incompetent cervix, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. 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 and this guideline were reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made according to the guidelines developed by The Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the ultrasonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth. SPONSORS: The Society of Obstetricians and Gynaecologists of Canada SUMMARY STATEMENTS: RECOMMENDATIONS.

Are There Differences between Women who Choose Elective Repeat Caesarean Versus Trial of Labour in St. John's, NL?

OBJECTIVES: To compare the demographic and clinical characteristics between women who chose elective repeat Caesarean section (ERCS) versus trial of labour after Caesarean section (TOLAC) in St. John's, Newfoundland and Labrador (NL). METHODS: We conducted a retrospective case control study of women with live singleton gestations delivering at term in St. John's, NL between January 1, 2001 and December 31, 2014. Inclusion criteria were women who had a previous single lower segment Caesarean section (LSCS). TOLAC, successful TOLAC, and VBAC rates were calculated. Demographic and clinical characteristics were compared between women who chose ERCS versus TOLAC. Univariate analyses and multiple logistic regression analyses were performed, and adjusted odds ratios (aOR) and 95% CIs were calculated. RESULTS: A total of 1579 women were included, of whom 160 (10.1%) chose TOLAC, with 107 resulting in successful VBAC (67% successful TOLAC rate). The overall VBAC rate was 6.8%. Women who chose ERCS compared with those who chose TOLAC were more likely to be obese (aOR 3.20, 95% CI 1.85-5.54, P < 0.001), less likely to have had GA at delivery greater than 40 weeks (aOR 0.13, 95% CI 0.08-0.21, P < 0.001), less likely to have had a previous vaginal delivery (aOR 0.40, 95% CI 0.20-0.80, P < 0.001), and less likely to have had the previous CS for breech presentation (aOR 0.51, 95% CI 0.33-0.80, P = 0.003). CONCLUSIONS: The overall TOLAC and VBAC rates in St. John's are low when compared with reported national rates. The successful TOLAC rate is within the expected range reported in the literature. Differences exist between women who chose ERCS compared with TOLAC.

A Common Language: What Exactly Does 34 Weeks Gestation Mean?

There are multiple conventions for gestational age notation, which lead to different interpretations of completed weeks. This variability is exemplified by the different gestational age ranges recommended for administration of antenatal corticosteroid prophylaxis. Antenatal corticosteroid prophylaxis is widely recommended for women at risk of preterm delivery up to 34 completed weeks gestation. According to the World Health Organization, 34 completed weeks refers to the time period from the first day of the last menstrual period (day zero) to 34 weeks and 6 days of gestation (i.e., to 34+6 34 weeks, or 244 days gestation). However, an alternative convention interprets 34 completed weeks as the period from the first day of the last menstrual period to 33+6 36 weeks' gestation (i.e., 237 days' gestation). These inconsistencies in gestational age notation may have led to different practice recommendations for antenatal corticosteroid prophylaxis worldwide. Agreeing on the World Health Organization notation and interpretation of completed weeks may help promote clear communication within our discipline and more precise and effective knowledge dissemination.

The Impact of Maternal Obesity on Breastfeeding.

OBJECTIVE: To compare the rate of any breastfeeding at the time of postpartum hospital discharge between obese women (BMI ≥ 30.00 kg/m(2)) and women with a normal BMI (18.50 to 24.99 kg/m(2)). METHODS: We conducted a retrospective cohort study of women with live, singleton pregnancies who delivered in St. John's, Newfoundland and Labrador between 2002 and 2011, using data from the Newfoundland and Labrador provincial perinatal registry. The primary outcome was any breastfeeding at the time of discharge from hospital. Secondary analysis included comparison of breastfeeding rates by class of obesity. We compared additional maternal and neonatal outcomes between women who were breastfeeding at discharge and those who were not. Univariate and multivariate logistic regression analyses were performed, and adjusted odds ratios (aORs) and 95% CIs were calculated. RESULTS: We included 12 831 women with BMI data available in the study: 8676 were breastfeeding and 4155 were not at the time of postpartum discharge. Obese women were less likely to breastfeed than women with normal weight (60.0% vs. 71.7%) (aOR 0.63; 95% CI 0.55 to 0.71). Multivariate analysis showed a significant effect on the primary outcome of a mother's age (aOR 1.03; 95% CI 1.02 to 1.05), nulliparity (aOR 1.73; 95% CI 1.51 to 1.98), being partnered (aOR 1.57; 95% CI 1.34 to 1.84), working (aOR 1.10; 95% CI 1.02 to 1.19), having higher education (aOR 1.48; 95% CI 1.38 to 1.60), smoking (aOR 0.35; 95% CI 0.29 to 0.43), having gestational diabetes (aOR 0.70; 95% CI 0.5 to 0.92), pre-existing hypertension (aOR 0.58; 95% CI 0.39 to 0.87), gestational hypertension (aOR 0.67; 95% CI 0.55 to 0.82), and undergoing general anaesthesia (aOR 0.41; 95% CI 0.22 to 0.77). CONCLUSION: Obesity is an independent risk factor for not breastfeeding at the time of postpartum discharge from hospital. It is important to counsel women on the benefits of breastfeeding, emphasizing these particularly in women with a high pre-pregnancy BMI.

Atonic Postpartum Hemorrhage: Blood Loss, Risk Factors, and Third Stage Management.

OBJECTIVE: Atonic postpartum hemorrhage rates have increased in many industrialized countries in recent years. We examined the blood loss, risk factors, and management of the third stage of labour associated with atonic postpartum hemorrhage. METHODS: We carried out a case-control study of patients in eight tertiary care hospitals in Canada between January 2011 and December 2013. Cases were defined as women with a diagnosis of atonic postpartum hemorrhage, and controls (without postpartum hemorrhage) were matched with cases by hospital and date of delivery. Estimated blood loss, risk factors, and management of the third stage labour were compared between cases and controls. Conditional logistic regression was used to adjust for confounding. RESULTS: The study included 383 cases and 383 controls. Cases had significantly higher mean estimated blood loss than controls. However, 16.7% of cases who delivered vaginally and 34.1% of cases who delivered by Caesarean section (CS) had a blood loss of < 500 mL and < 1000 mL, respectively; 8.2% of controls who delivered vaginally and 6.7% of controls who delivered by CS had blood loss consistent with a diagnosis of postpartum hemorrhage. Factors associated with atonic postpartum hemorrhage included known protective factors (e.g., delivery by CS) and risk factors (e.g., nulliparity, vaginal birth after CS). Uterotonic use was more common in cases than in controls (97.6% vs. 92.9%, P < 0.001). Delayed cord clamping was only used among those who delivered vaginally (7.7% cases vs. 14.6% controls, P = 0.06). CONCLUSION: There is substantial misclassification in the diagnosis of atonic postpartum hemorrhage, and this could potentially explain the observed temporal increase in postpartum hemorrhage rates.

Maternal and perinatal outcomes of pregnancies delivered at 23 weeks' gestation.

OBJECTIVE: To evaluate the maternal and perinatal outcomes of pregnancies delivered at 23+0 to 23+6 weeks' gestation. METHODS: This prospective cohort study included women in the Canadian Perinatal Network who were admitted to one of 16 Canadian tertiary perinatal units between August 1, 2005, and March 31, 2011, and who delivered at 23+0 to 23+6 weeks' gestation. Women were included in the network if they were admitted with spontaneous preterm labour with contractions, a short cervix without contractions, prolapsing membranes with membranes at or beyond the external os or a dilated cervix, preterm premature rupture of membranes, intrauterine growth restriction, gestational hypertension, or antepartum hemorrhage. Maternal outcomes included Caesarean section, placental abruption, and serious complication. Perinatal outcomes were mortality and serious morbidity. RESULTS: A total of 248 women and 287 infants were included in the study. The rate of Caesarean section was 10.5% (26/248) and 40.3% of women (100/248) had a serious complication, the most common being chorioamnionitis (38.6%), followed by blood transfusion (4.5%). Of infants with known outcomes, perinatal mortality was 89.9% (223/248) (stillbirth 23.3% [67/287] and neonatal death 62.9% [156/248]). Of live born neonates with known outcomes (n = 181), 38.1% (69/181) were admitted to NICU. Of those admitted to NICU, neonatal death occurred in 63.8% (44/69). Among survivors at discharge, the rate of severe brain injury was 44.0% (11/25), of retinopathy of prematurity 58.3% (14/24), and of any serious neonatal morbidity 100% (25/25). Two subgroup analyses were performed: in one, antepartum stillbirths were excluded, and in the other only centres that indicated they offered fetal monitoring at 23 weeks' gestation were included and antepartum stillbirths were excluded. In each of these, perinatal outcomes similar to the overall group were found. CONCLUSION: Pregnant women delivering at 23 weeks' gestation are at risk of morbidity. Their infants have high rates of serious morbidity and mortality. Further research is needed to identify strategies and forms of management that not only increase perinatal survival but also reduce morbidities in these extremely low gestational age infants and reduce maternal morbidity.

Objectif : Évaluer les issues maternelles et périnatales des grossesses donnant lieu à un accouchement entre 23+0 et 23+6 semaines de gestation. Méthodes : Cette étude de cohorte prospective portait sur des femmes du Réseau périnatal canadien qui ont été admises à l'une des 16 unités périnatales tertiaires canadiennes participantes entre le 1er août 2005 et le 31 mars 2011, et qui ont accouché entre 23+0 et 23+6 semaines de gestation. Les femmes ont été admises dans le réseau si elles avaient été hospitalisées en raison d'un travail préterme spontané (s'accompagnant de contractions), d'un col court (sans contractions), d'un prolapsus des membranes (s'accompagnant d'une dilatation du col ou dans le cadre duquel les membranes se situaient au niveau de l'orifice externe ou faisaient saillie au-delà de ce dernier), d'une rupture prématurée des membranes préterme, d'un retard de croissance intra-utérin, d'une hypertension gestationnelle ou d'une hémorragie antepartum. Parmi les issues maternelles, on trouvait la césarienne, le décollement placentaire et la manifestation d'une complication grave. La morbidité grave et la mortalité constituaient les issues périnatales. Résultats : En tout, 248 femmes et 287 nouveau-nés ont été inclus dans l'étude. Le taux de césarienne était de 10,5 % (26/248) et 40,3 % des femmes (100/248) ont connu une complication grave (la plus courante étant la chorioamnionite [38,6 %], suivie de la transfusion sanguine [4,5 %]). Parmi les nouveau-nés pour lesquels les issues étaient connues, le taux de mortalité périnatale était de 89,9 % (223/248) (taux de mortinaissance : 23,3 % [67/287] et taux de décès néonatal : 62,9 % [156/248]). Une admission à l'UNSI a été requise pour 38,1 % (69/181) des enfants nés vivants pour lesquels les issues étaient connues (n = 181). Parmi ces enfants ayant dû être admis à l'UNSI, un décès néonatal a été constaté dans 63,8 % (44/69) des cas. Chez les survivants (au moment de l'obtention de leur congé de l'UNSI), le taux de lésion cérébrale grave était de 44,0 % (11/25), le taux de rétinopathie des prématurés était de 58,3 % (14/24) et le taux de quelque morbidité néonatale grave que ce soit était de 100 % (25/25). Deux analyses de sous-groupe ont été menées : dans le cadre de l'une d'entre elles, les mortinaissances pendant la période antepartum ont été exclues; dans le cadre de l'autre, seuls les centres ayant indiqué qu'ils offraient le monitorage fœtal à 23 semaines de gestation ont été inclus et les mortinaissances pendant la période antepartum ont également été exclues. Des issues périnatales semblables à celles du groupe général ont été constatées dans chacune de ces analyses. Conclusion : Les femmes enceintes qui accouchent à 23 semaines de gestation sont exposées à des risques de morbidité. Leurs nouveau-nés présentent des taux élevés de morbidité grave et de mortalité. La poursuite de la recherche s'avère requise pour permettre l'identification de stratégies et de formes de prise en charge qui entraînent non seulement une amélioration du taux de survie périnatale, mais également une baisse des taux de morbidité que connaissent ces nouveau-nés d'âge gestationnel extrêmement faible et les mères.

Maternal and perinatal outcomes of extreme obesity in pregnancy.

OBJECTIVE: To evaluate the effects of extreme obesity (pre-pregnancy BMI ≥ 50.0 kg/m2) in pregnancy on maternal and perinatal outcomes. METHODS: We conducted a population-based cohort study using the Newfoundland and Labrador Perinatal Database to compare obstetric outcomes in women with extreme obesity and those with a normal BMI (pre-pregnancy BMI 18.50 to 24.99 kg/m2). We included women with singleton gestations who gave birth between January 1, 2002, and December 31, 2011. Maternal outcomes of interest included gestational hypertension, gestational diabetes, Caesarean section, shoulder dystocia, length of hospital stay, maternal ICU admission, postpartum hemorrhage, and death. Perinatal outcomes included birth weight, preterm birth, Apgar score, neonatal metabolic abnormality, NICU admission, stillbirth, and neonatal death. A composite morbidity outcome was developed including at least one of Caesarean section, gestational hypertension, birth weight ≥ 4000 g, birth weight < 2500 g, or NICU admission. Univariate analyses and multivariate logistic regression analyses (controlling for maternal age, parity, smoking, partner status, and gestational age) were performed, and adjusted odds ratios (aORs) and 95% confidence intervals were calculated. RESULTS: A total of 5788 women were included in the study: 71 with extreme obesity and 5717 with a normal BMI. Extremely obese women were more likely to have gestational hypertension (19.7% vs. 4.8%) (aOR 1.56; 95% CI 1.33 to 1.82), gestational diabetes (21.1% vs. 1.5%) (aOR 2.04; 95% CI 1.74 to 2.38), shoulder dystocia (7.1% vs. 1.4%) (aOR 1.51; 95% CI 1.05 to 2.19), Caesarean section (60.6% vs. 25.0%) (aOR 1.46; 95% CI 1.29 to 1.65), length of hospital stay more than five days (excluding Caesarean section) (14.3% vs. 4.7%) (aOR 1.42; 95% CI 1.07 to 1.89), birth weight ≥ 4000 g (38.0% vs. 11.9%) (aOR 1.58; 95% CI 1.38 to 1.80), birth weight ≥ 4500 g (16.9% vs. 2.1%) (aOR 1.87; 95% CI 1.57 to 2.23), neonatal metabolic abnormality (8.5% vs. 2.0%) (aOR 1.50; 95% CI 1.20 to 1.86), NICU admission (16.9% vs. 7.8%) (aOR 1.28; 95% CI 1.07 to 1.52), stillbirth (1.4% vs. 0.2%) (aOR 1.68; 95% CI 1.00 to 2.82) and composite adverse outcome (81.7% vs. 41.5%) (aOR 1.57; 95% CI 1.35 to 1.83). CONCLUSION: Women with extreme obesity have increased risks of a variety of adverse maternal and perinatal outcomes. As approximately 6 per 1000 women giving birth in our population have extreme obesity, it is important to address these risks pre-conceptually and encourage a healthier BMI before pregnancy.

Objectif : Évaluer les effets de l'obésité extrême (IMC prégrossesse ≥ 50,0 kg/m2) pendant la grossesse sur les issues maternelles et périnatales. Méthodes : Nous avons mené une étude de cohorte en population générale au moyen de la Newfoundland and Labrador Perinatal Database en vue de comparer les issues obstétricales des femmes présentant une obésité extrême à celles des femmes dont l'IMC est normal (IMC prégrossesse allant de 18,50 à 24,99 kg/m2). Nous avons inclus les femmes qui connaissaient une grossesse monofœtale et qui ont accouché entre le 1er janvier 2002 et le 31 décembre 2011. Parmi les issues maternelles d'intérêt, on trouvait l'hypertension gestationnelle, le diabète gestationnel, la césarienne, la dystocie de l'épaule, la durée de l'hospitalisation, l'admission à l'unité maternelle de soins intensifs, l'hémorragie postpartum et la mort. Parmi les issues périnatales, on trouvait le poids de naissance, l'accouchement préterme, l'indice d'Apgar, les anomalies métaboliques néonatales, l'admission à l'UNSI, la mortinaissance et le décès néonatal. Une issue composite en matière de morbidité a été élaborée; on y retrouve au moins un des facteurs suivants : césarienne, hypertension gestationnelle, poids de naissance ≥ 4 000 g, poids de naissance < 2 500 g ou admission à l'UNSI. Des analyses univariées et des analyses de régression logistique multivariée (neutralisant l'effet de l'âge maternel, de la parité, du tabagisme, de l'état quant à la présence ou non d'un partenaire et de l'âge gestationnel) ont été menées, et des rapports de cotes corrigés (RCc) et des intervalles de confiance à 95 % ont été calculés. Résultats : Au total, 5 788 femmes ont été incluses à l'étude : 71 présentant une obésité extrême et 5 717 présentant un IMC normal. Les femmes extrêmement obèses étaient plus susceptibles de connaître ce qui suit : hypertension gestationnelle (19,7 % vs 4,8 %) (RCc 1,56; IC à 95 %, 1,33 - 1,82), diabète gestationnel (21,1 % vs 1,5 %) (RCc 2,04; IC à 95 %, 1,74 - 2,38), dystocie de l'épaule (7,1 % vs 1,4 %) (RCc 1,51; IC à 95 %, 1,05 - 2,19), césarienne (60,6 % vs 25,0 %) (RCc 1,46; IC à 95 %, 1,29 - 1,65), hospitalisation de plus de cinq jours (cas de césarienne exclus) (14,3 % vs 4,7 %) (RCc 1,42; IC à 95 %, 1,07 - 1,89), poids de naissance ≥ 4 000 g (38,0 % vs 11,9 %) (RCc 1,58; IC à 95 %, 1,38 - 1,80), poids de naissance ≥ 4 500 g (16,9 % vs 2,1 %) (RCc 1,87; IC à 95 %, 1,57 - 2,23), anomalie métabolique néonatale (8,5 % vs 2,0 %) (RCc 1,50; IC à 95 %, 1,20 - 1,86), admission à l'UNSI (16,9 % vs 7,8 %) (RCc 1,28; IC à 95 %, 1,07 - 1,52), mortinaissance (1,4 % vs 0,2 %) (RCc 1,68; IC à 95 %, 1,00 - 2,82) et issue indésirable composite (81,7 % vs 41,5 %) (RCc 1,57; IC à 95 %, 1,35 - 1,83). Conclusion : Les femmes qui présentent une obésité extrême sont exposées à des risques accrus de connaître une variété d'issues indésirables maternelles et périnatales. Puisque, au sein de notre population, environ six parturientes sur 1 000 présentent une obésité extrême, il est important de traiter de ces risques avant la conception et d'inciter les patientes à obtenir un IMC plus santé avant de devenir enceintes.

SOGC Clinical Practice Guideline. Ultrasonographic cervical length assessment in predicting preterm birth in singleton pregnancies.

OBJECTIVES: To review (1) the use of ultrasonographic-derived cervical length measurement in predicting preterm birth and (2) interventions associated with a short cervical length. OUTCOMES: Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions. EVIDENCE: Published literature was retrieved through searches of PubMed and The Cochrane Library up to December 2009, using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, incompetent cervix, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. 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 and this guideline were reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made according to the guidelines developed by The Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the ultrasonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth. SPONSORS: The Society of Obstetricians and Gynaecologists of Canada.

The Canadian Perinatal Network: a national network focused on threatened preterm birth at 22 to 28 weeks' gestation.

OBJECTIVE: The Canadian Perinatal Network (CPN) maintains an ongoing national database focused on threatened very preterm birth. The objective of the network is to facilitate between-hospital comparisons and other research that will lead to reductions in the burden of illness associated with very preterm birth. METHODS: Women were included in the database if they were admitted to a participating tertiary perinatal unit at 22+0 to 28+6 weeks' gestation with one or more conditions most commonly responsible for very preterm birth, including spontaneous preterm labour with contractions, incompetent cervix, prolapsing membranes, preterm prelabour rupture of membranes, gestational hypertension, intrauterine growth restriction, or antepartum hemorrhage. Data were collected by review of maternal and infant charts, entered directly into standardized electronic data forms and uploaded to the CPN via a secure network. RESULTS: Between 2005 and 2009, the CPN enrolled 2524 women from 14 hospitals including those with preterm labour and contractions (27.4%), short cervix without contractions (16.3%), prolapsing membranes (9.4%), antepartum hemorrhage (26.1%), and preterm prelabour rupture of membranes (23.0%). The mean gestational age at enrolment was 25.9 ± 1.9 weeks and the mean gestation age at delivery was 29.9 ± 5.1 weeks; 57.0% delivered at < 29 weeks and 75.4% at < 34 weeks. Complication rates were high and included serious maternal complications (26.7%), stillbirth (8.2%), neonatal death (16.3%), neonatal intensive care unit admission (60.7%), and serious neonatal morbidity (35.0%). CONCLUSION: This national dataset contains detailed information about women at risk of very preterm birth. It is available to clinicians and researchers who are working with one or more CPN collaborators and who are interested in studies relating processes of care to maternal or perinatal outcomes.

The effect of gestational weight gain by body mass index on maternal and neonatal outcomes.

OBJECTIVE: To evaluate the effects of gestational weight gain on maternal and neonatal outcomes in different body mass index (BMI) classes. METHODS: We compared maternal and neonatal outcomes based on gestational weight gain in underweight, normal weight, overweight, obese, and morbidly obese (BMI>or=40.00) women. The study group was a population-based cohort of women with singleton gestations who delivered between April 1, 2001, and March 31, 2007, drawn from the Newfoundland and Labrador Provincial Perinatal Program Database. Univariate analyses and multivariate logistic regression analyses (controlling for maternal age, parity, smoking status, partnered status, and gestational age) were performed and odds ratios (ORs) were calculated. RESULTS: Only 30.6% of women gained the recommended amount of weight during pregnancy; 52.3% of women gained more than recommended, and 17.1% gained less than recommended. In women with normal pre-pregnancy BMI, excess weight gain was associated with increased rates of gestational hypertension (OR 1.27; 95% CI 1.08-1.49), augmentation of labour (OR 1.09; 95% CI 1.01-1.18), and birth weight>or=4000 g (OR 1.21; 95% CI 1.10-1.34). In overweight women, excess weight gain was associated with increased rates of gestational hypertension (OR 1.31; 95% CI 1.10-1.55) and birth weight>or=4000 g (OR 1.30; 95% CI 1.15-1.47). In women who were obese or morbidly obese, excess weight gain was associated with increased rates of birth weight>or=4000 g (OR 1.20; 95% CI 1.07-1.34) and neonatal metabolic abnormality (OR 1.31; 95% CI 1.00-1.70). In morbidly obese women, poor weight gain was associated with less use of epidural analgesia (OR 0.34; 95% CI 0.12-0.95). In women who were of normal weight, overweight, or obese, the rate of adverse outcome (Caesarean section, gestational hypertension, birth weight<2500 g or birth weight>or=4000 g) was lower in women with recommended weight gain than in those with excess weight gain. Adverse outcomes were reduced in nulliparous morbidly obese women who had poor weight gain (OR 0.18; 95% CI 0.04-0.83). CONCLUSION: The effects of gestational weight gain on pregnancy outcome depend on the woman's pre-pregnancy BMI. Pregnancy weight gains of 6.7-11.2 kg (15-25 lb) in overweight and obese women, and less than 6.7 kg (15 lb) in morbidly obese women are associated with a reduction in the risk of adverse outcome.

Randomized trial of oral misoprostol before endometrial biopsy.

OBJECTIVE: To determine if the use of oral misoprostol in women undergoing endometrial biopsy reduces procedural discomfort. METHODS: Women undergoing endometrial biopsy were randomized to receive either 400 microg misoprostol or a vitamin B6 placebo orally 12 hours prior to the procedure, and were stratified based on menopausal status. The primary outcome was procedural discomfort on a visual analogue scale (0-10). Secondary outcomes included the need to dilate the cervix or use a tenaculum, and side effects. Subgroup analyses were planned for premenopausal and postmenopausal women separately. Sample size calculation was based on detecting a 50% reduction in pain, with alpha = 0.05 and beta = 0.10, in the premenopausal group. RESULTS: A total of 72 women (49 premenopausal and 23 postmenopausal) were enrolled; 35 received misoprostol (23 premenopausal and 12 postmenopausal) and 37 received placebo (26 premenopausal and 11 postmenopausal). There were no significant differences in procedural discomfort (misoprostol vs. placebo 5.8 +/- 2.9 vs. 5.5 +/- 3.2, P = 0.77; premenopausal women 4.9 +/- 3.3 vs. 5.1 +/- 3.1, P = 0.85; postmenopausal women 7.1 +/- 1.9 vs. 7.1 +/- 2.3, P = 0.99), need to dilate the cervix (6.1% vs. 5.6%, P = 0.93) or use a tenaculum (44.1% vs. 48.6%, P = 0.70). Significantly more women in the misoprostol group experienced nausea (31.4% vs. 2.7%, P = 0.001), diarrhea (20.0% vs. 2.7%, P = 0.02), abdominal pain (22.9% vs. 5.4%, P = 0.03), menstrual-like cramping (42.9% vs. 2.7%, P < 0.001) and vaginal bleeding (11.4% vs. 0%, P = 0.03). CONCLUSION: The use of 400 microg oral misoprostol 12 hours prior to endometrial biopsy did not reduce procedural discomfort and was associated with more side effects than use of placebo. This finding was noted in all women as well as among subgroups of premenopausal and postmenopausal women.

A comparison of breastfeeding rates by obesity class.

PURPOSE: The purpose of this study is to compare breastfeeding initiation rates for women across body mass index (BMI) classes, including normal BMI (18.50-24.99 kg/m2), overweight (25.00-29.99 kg/m2), obese (30.00-39.99 kg/m2), morbidly obese (40.00-49.99 kg/m2) and extreme obesity (≥50.00 kg/m2). MATERIALS AND METHODS: Retrospective cohort of women with singleton pregnancies, delivering in St. John's, NL between 2002 and 2011. The primary outcome was any breastfeeding on hospital discharge. Breastfeeding rates across BMI categories were compared, using univariate analyses. Multivariate analysis included additional maternal and obstetric variables. RESULTS: Twelve thousand four hundred twenty-two women were included: 8430 breastfed and 3992 did not breastfeed on hospital discharge. Progressively decreasing rates of breastfeeding were noted with increasing obesity class: normal BMI (71.1%), overweight (69.1%), obese (61.6%), morbidly obese (54.2%), and extremely obese women (42.3%). Multivariate analysis confirmed that increasing obesity class resulted in lower odds of breastfeeding: overweight (adjusted odds ratios (aOR) 0.86, 95%CI 0.76-0.98), obese (aOR 0.65, 95%CI 0.57-0.74), morbidly obese (aOR 0.57, 95%CI 0.44-0.74), and extreme obesity (aOR 0.37, 95%CI 0.19-0.74). CONCLUSION: Women in higher obesity classes are progressively less likely to initiate breastfeeding. Women with the highest prepregnancy BMIs should be particularly counseled on the benefits of breastfeeding.

A randomized trial of oral misoprostol in premenopausal women before hysteroscopy.

OBJECTIVE: To determine if the use of oral misoprostol in premenopausal women undergoing diagnostic hysteroscopy produces a clinically important difference in pre-procedural cervical dilatation. METHODS: At a tertiary care hospital, premenopausal women undergoing diagnostic hysteroscopy were randomized to receive either 400 microg of misoprostol or a vitamin B6 placebo orally 12 hours before the procedure. Patients were stratified on the basis of parity. The primary outcome was the pre-procedural dilatation of the cervix. Secondary outcomes included the need to further dilate the cervix, the time required to further dilate the cervix, and side effects. RESULTS: Sixty-four women (11 nulliparous and 53 parous) undergoing diagnostic hysteroscopy consented to participate in the study. Thirty-three women received misoprostol and 31 received placebo. Baseline demographics showed no difference in age and parity between the two groups. There were no significant differences in pre-procedural dilatation (5.0 mm vs. 4.7 mm, P = 0.52), need to further dilate the cervix (56.7% vs. 63.0%, P = 0.63), and time required to further dilate the cervix (12.7 seconds vs. 25.7 seconds, P = 0.27). Significantly more women in the misoprostol group experienced menstrual-like cramping (24.2% vs. 3.3%, P = 0.03) and vaginal spotting (21.2% vs. 3.3%, P = 0.05). CONCLUSION: In premenopausal women, there is no improvement in pre-procedural cervical dilatation with administration of oral misoprostol 12 hours before diagnostic hysteroscopy. Further research is required in both nulliparous and parous premenopausal women to determine whether oral misoprostol improves cervical dilatation and, if so, the ideal dose, route and timing.

Rectal misoprostol versus oxytocin in the management of the third stage of labour.

OBJECTIVE: To compare the effect of rectal misoprostol with intramuscular oxytocin in the routine management of the third stage in a rural developing country. METHODS: A randomized controlled trial was performed at two district hospitals in Ghana, West Africa. Four hundred fifty women in advanced labour were enrolled. The only exclusion criterion was a known medical contraindication to prostaglandin administration. Women were randomized to receive rectal misoprostol 800 microg or intramuscular oxytocin 10 IU with delivery of the anterior shoulder. The main outcome measure was change in hemoglobin concentration from before to after delivery. Secondary outcomes included the need for additional uterotonics, estimated blood loss, transfusion, and medication side effects. RESULTS: Demographic characteristics were similar in each treatment group. There was no significant difference between treatment groups in change in hemoglobin (misoprostol 1.19 g/dL and oxytocin 1.16 g/dL; relative difference 2.6%; 95% confidence intervals [CI]-16.8% to 19.4%; P = 0.80). The only significant secondary outcome was shivering, which was more common in the misoprostol group (misoprostol 7.5% vs. oxytocin 0.9%; relative risk 8.0; 95% CI 1.86-34.36; P = 0.001). CONCLUSION: Rectal misoprostol 800 microg is as effective as 10 IU intramuscular oxytocin in minimizing blood loss in the third stage of labour. Rectal misoprostol has a lower incidence of side effects than the equivalent oral dose. This confirms the utility of misoprostol as a safe and effective uterotonic for use in the rural and remote areas of developing nations where other pharmacologic agents may be less feasible.

Transvaginal ultrasonography in the prediction of preterm birth after treatment for cervical intraepithelial neoplasia.

OBJECTIVE: To estimate whether cervical length measured by transvaginal ultrasonography in women having had loop electrosurgical excision procedure (LEEP), cold knife conization, or cryotherapy predicts spontaneous preterm birth. METHODS: Women with a history of LEEP, cold knife conization, or cryotherapy and who were subsequently pregnant with singleton gestations were prospectively compared with both a low-risk control group and women with previous spontaneous preterm birth. A transvaginal ultrasonogram measuring cervical length was performed at 24 to 30 weeks of gestation. Primary outcomes included cervical length and spontaneous preterm birth less than 37 weeks. Secondary outcomes were spontaneous preterm birth less than 34 weeks, low birth weight, and maternal and neonatal outcomes. RESULTS: Women with previous LEEP (N = 75), cold knife conization (N = 21), and cryotherapy (N = 36) had shorter cervical lengths (3.54, 3.69, and 3.75 cm respectively) than the low-risk control group (N = 81, 4.21 cm) (P < .001, P = .03, P = .02 respectively) and similar lengths to women with a previous spontaneous preterm birth (N = 63, 3.78 cm). Loop electrosurgical excision procedure and cold knife conization, but not cryotherapy, were associated with spontaneous preterm birth less than 37 weeks (odds ratio 3.45, 95% confidence interval 1.28-10.00, P = .02; and odds ratio 2.63, 95% confidence interval 1.28-5.56, P = .009, respectively). Using a cutoff of 3.0 cm, transvaginal ultrasonography had a positive predictive value of 53.8% and negative predictive value of 95.2% for spontaneous preterm birth less than 37 weeks in women with LEEP. CONCLUSION: Women with a history of LEEP, cold knife conization, and cryotherapy all independently have shorter cervical lengths than low-risk controls and similar lengths to women with previous spontaneous preterm birth. Loop electrosurgical excision procedure and cold knife conization are associated with spontaneous preterm birth less than 37 weeks, and transvaginal ultrasonography predicts preterm birth in women who have had LEEP. LEVEL OF EVIDENCE: II-2.