Pregnancy planning may impact maternal and neonatal outcomes in people with myasthenia gravis.

INTRODUCTION: Myasthenia Gravis (MG) is an acquired autoimmune condition commonly diagnosed in young people of reproductive age resulting in neuromuscular junction dysfunction. The course of MG during pregnancy and its impact on maternal and neonatal outcomes is vary in the literature. Pregnancy planning is a known strategy and modifiable risk factor in obstetric practice to decrease maternal and neonatal morbidity. We aim to assess if planning a pregnancy impacts maternal and neonatal outcomes, MG exacerbation, and pregnancy-related complications. METHODS: This study utilized data from an online, North American survey entitled "A Patient Centered study on Pregnancy in People with Myasthenia Gravis", distributed with the assistance of MG advocacy groups in the United States and Canada. It included individuals with MG who had at least one pregnancy in the last 10-years. Key maternal and neonatal outcomes were compared between planned and unplanned pregnancies. RESULTS: Out of 156 survey participants, 58 had a pregnancy following MG diagnosis, totaling 90 reported pregnancies. Of these, 56 (62.2%) were planned and 34 (37.8%) were unplanned pregnancies. The unplanned pregnancies were associated with more MG exacerbations, hospitalizations, and intensive care unit admission (37.7% vs. 13.7%, 26.5% vs. 11%, and 17.6% vs. 8.9%, respectively, p ≤ .05). The neonatal outcomes did not significantly differ between the groups. DISCUSSION: Planned pregnancies in people with MG may be associated with a reduced gestational and post-partum risk of MG exacerbation, hospitalizations, and ICU admissions. Larger studies are required to confirm this association and account for potential contributing variables.

Obstetric and Neonatal Outcomes in People Who Acquired a Spinal Cord Injury During Pregnancy.

OBJECTIVE: The objectives of this study were to determine the obstetric and neonatal outcomes of people who acquired spinal cord injuries (SCI) during pregnancy. METHODS: This is part of an international observational questionnaire examining pregnancy outcomes of people with SCI. The outcome measures included demographics, level of injury and American Spinal Injury Association scores, prenatal and postnatal complications, and neonatal outcomes. RESULTS: Of 780 responses, 14 (1.79%) participants reported acquiring an SCI while pregnant. 64.2% (9/14) of injuries were due to trauma. Of 14 pregnancies, 1 person miscarried, and 3 pregnancies were terminated. There were 11 live births. One participant had twins and 9 live births were singletons. Six participants delivered vaginally, 3 had a cesarean delivery and 1 was unreported. The preterm birth rate was 54.5% (6/11). Approximately 36% (4/11) of newborns were admitted to the neonatal intensive care unit. The average birth weight reported was 2409.7 g (456.3 g-3458.6 g). Forty percent (4/10) of participants reported experiencing postpartum blues or depression. Sixty percent (6/10) of participants breastfed for over 2 weeks. CONCLUSIONS: This is the largest known cohort to date of persons acquiring SCI during pregnancy. The most common cause of SCI was a motor vehicle accident. Complications included preterm birth and neonatal intensive care unit admission. People who have an SCI during pregnancy are at risk for complications; however, positive pregnancy and neonatal outcomes are possible. Absolute small numbers of this event limit the ability to assess incidence of outcomes.

Fetal Ultrasound Challenges and Solutions for Scanning Pregnant People With Physical Disabilities: A Two-Year Initiative for Adaptation.

The Accessible Care Pregnancy Clinic provides consolidated pregnancy care, including ultrasound, for people with physical disabilities. Sonography was identified as likely presenting unique challenges for this population. Therefore, over a 2-year period, sonographers recorded notes describing ultrasound techniques and challenges on 136 scans from 23 patients. These notes, along with ongoing communication between sonographers, administrative staff, nurses, and physicians, informed troubleshooting, which included preparing equipment, scheduling extra time with patients, and including support people. Final feedback revealed that sonographers experienced increased comfort and skill scanning people with physical disabilities and felt tht longer booking times, larger space, and partnering with the individual throughout their pregnancy improved quality of care.

Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities.

OBJECTIVE: To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada. TARGET POPULATION: This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline. OUTCOMES: Safe and compassionate care for people with physical disabilities who are giving birth. BENEFITS, HARMS, AND COSTS: Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth. EVIDENCE: A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

Osteogenesis Imperfecta Type V in a Mother and Baby Pair: First Case Report of Pregnancy and Delivery.

BACKGROUND: Osteogenesis imperfecta (OI) is a rare condition with limited data on fetal and maternal impact for almost all subtypes. OI type V is a very rare, autosomal dominant, inherited subtype of OI. The care of pregnant women with OI is managed by an interdisciplinary team, and fetal diagnosis is possible through amniocentesis, which may assist in delivery planning. CASE: This report is the first to describe a case of maternal and fetal OI type V. We detail maternal and fetal management during pregnancy and delivery planning. While no major complications occurred during pregnancy or delivery, the neonate developed multiple fractures in the first few months of life. CONCLUSION: Our case shows favourable maternal and pregnancy outcomes with OI type V and emphasizes the importance of fetal diagnosis.

Comparing Foley Catheter to Prostaglandins for Cervical Ripening in Multiparous Women.

OBJECTIVE: This study sought to test the hypothesis that among multiparous women requiring cervical ripening, mechanical ripening with a Foley catheter is more effective than prostaglandin preparations. METHODS: This was a retrospective analysis of multiparous women with a singleton gestation who required cervical ripening in a single tertiary center from 2014 to 2019. Women who underwent cervical ripening with a Foley catheter (Foley group) were compared with women who underwent cervical ripening using a controlled-release dinoprostone vaginal insert (PGE2-CR group) or dinoprostone vaginal gel (PGE2-gel group). The primary outcome was the ripening-to-delivery interval. RESULTS: A total of 229 women met the study criteria (Foley group: 95; PGE2-CR group: 83; PGE2-gel group: 51). Women in the Foley group had a significantly shorter ripening-to-delivery interval compared with women in the PGE2-CR group (16.2 ± 9.2 hours vs. 27.0 ± 14.8 hours; P < 0.001) and were more likely to deliver within 12 hours (47.4% vs. 12.0%; P < 0.001; adjusted relative risk [aRR] 3.87; 95% confidence interval [CI] 2.07-7.26) and within 24 hours (78.9% vs. 49.4%; P < 0.001; aRR 1.61; 95% CI 1.26-2.06). Women in the Foley group were also less likely to require a second ripening method compared with women in the PGE2-CR group (1.1% vs. 8.4%; P = 0.018; aRR 7.26; 95% CI 2.99-17.62). These differences were not observed when comparing the Foley and the PGE2-gel groups. The cesarean section rate was similar among the Foley group (9.5%), PGE2-CR group (9.6%; P = 0.970), and PGE2-gel group (11.8%; P = 0.664). CONCLUSION: In multiparous women requiring cervical ripening, all methods of cervical ripening have a similar success rate. However, the use of a PGE2-CR insert is associated with a considerably longer interval to delivery compared with a Foley catheter or PGE2 gel.

Pregnancy 5 Years After Onset of Amyotrophic Lateral Sclerosis Symptoms: A Case Report and Review of the Literature.

BACKGROUND: Pregnancy in patients with amyotrophic lateral sclerosis (ALS) is extremely rare and often results in delivery of a healthy baby when patients are in the early stages of the disease. CASE: This report describes the case of a successful pregnancy 5 years after ALS onset. Significant worsening of weakness, unsteady balance, and dysphagia were noticed around the third trimester. A healthy child was delivered at term by planned Caesarean section. After delivery the patient developed remarkable weakness, dysphagia, and dysarthria. CONCLUSION: A literature search found 22 cases through PubMed and Ovid, with key words "amyotrophic lateral sclerosis" and "pregnancy." Both slow progression and rapid progression of ALS during pregnancy have been reported. Worsening of symptoms seems to be common, but little is still known about the influence of pregnancy on ALS onset and progression.

Fetal echocardiography assists in determining optimal delivery site.

OBJECTIVE: Congenital heart disease is one of the most common types of structural fetal abnormalities and a major cause of perinatal morbidity and mortality. Fetal echocardiography aids in the diagnosis of congenital heart disease, which allows management planning for parents and physicians, including continuation or termination of the pregnancy and triaging for location of delivery. This is a key component of planning, as transport of neonates entails risks, costs, and parental stress. In this study, we examined the outcomes of pregnancies with fetal cardiac anomalies diagnosed at a single tertiary care centre. We aimed to assess whether the system of directing affected pregnancies to either a tertiary and quaternary care centre is effective. METHODS: We identified pregnancies with fetal cardiac anomalies diagnosed on fetal echocardiography between 2005 and 2009. Information about diagnosis, pregnancy outcome, delivery location, and surgical management was collected. This information was analyzed retrospectively. RESULTS: Anomalies were demonstrated in 120 fetal echocardiography studies. Four of the babies (3.3%) were stillborn, and 27 (22.5%) pregnancies were terminated. There were 89 live born babies, and 74 of these (61.7%) survived the neonatal period. Fifteen babies (12.5%) died as neonates. Thirty-two pregnant women were triaged to deliver at the quaternary centre with pediatric cardiac surgery services, and 20 of these babies underwent surgery. Two of the 89 live born babies (2.2%) required emergency transfer. CONCLUSION: Fetal echocardiography is an important contributor to efficient use of pediatric cardiac services and minimizes need for neonatal transfer. Contemporary use of fetal echocardiography is associated with optimized delivery location.

Objectif : La cardiopathie congénitale est l'un des types les plus courants d'anomalies fœtales structurales et constitue une cause importante de morbidité et de mortalité périnatales. L'échocardiographie fœtale contribue au diagnostic de la cardiopathie congénitale, ce qui permet la planification de la prise en charge pour les parents et les médecins (y compris la prise d'une décision quant à la poursuite ou à l'interruption de la grossesse et la détermination de l'endroit de l'accouchement). Il s'agit d'une composante clé de la planification, puisque le transport des nouveau-nés engendre des risques, des coûts et du stress parental. Au cours de cette étude, nous nous sommes penchés sur les issues des grossesses dans le cadre desquelles des anomalies cardiaques fœtales ont été diagnostiquées au sein d'un seul centre de soins tertiaires. Nous avons cherché à déterminer si le système assurant l'orientation des grossesses affectées à un centre de soins tertiaires ou quaternaires était efficace. Méthodes : Nous avons identifié les grossesses dans le cadre desquelles l'échocardiographie fœtale avait permis le diagnostic d'anomalies cardiaques fœtales entre 2005 et 2009. Des renseignements au sujet du diagnostic, de l'issue de grossesse, du lieu de l'accouchement et de la prise en charge chirurgicale ont été recueillis. Ces renseignements ont fait l'objet d'une analyse rétrospective. Résultats : Des anomalies a été constatées dans 120 études d'échocardiographie fœtale. Quatre des enfants (3,3 %) sont mort-nés et 27 grossesses (22,5 %) ont fait l'objet d'une interruption. Quatre-vingt-neuf naissances vivantes ont été constatées et 74 de ces nouveau-nés (61,7 %) ont survécu à la période néonatale (quinze enfants [12,5 %] sont morts pendant cette période). Trente-deux femmes enceintes ont été orientées vers un centre de soins quaternaires disposant d'un service de chirurgie cardiaque pédiatrique aux fins de l'accouchement; 20 des enfants issus de ces femmes ont subi une chirurgie. Deux des 89 enfants nés vivants (2,2 %) ont nécessité un transfert d'urgence. Conclusion : L'échocardiographie fœtale contribue de façon importante à l'utilisation efficace des services pédiatriques de cardiologie et minimise la nécessité d'avoir recours à un transfert néonatal. L'utilisation contemporaine de l'échocardiographie fœtale est associée à l'optimisation du choix du lieu de l'accouchement.

Does cervical ripening at term using a high volume foley catheter result in a lower caesarean section rate than a low volume foley catheter? A systematic review and meta-analysis.

Cervical ripening with a Foley catheter before induction of labour is a common obstetrical intervention. In this study we aimed to evaluate primarily the relationship between high or low volume Foley catheters used for cervical ripening and Caesarean section, and secondarily the relationship between Foley catheter volume, cervical ripeness, and time to delivery. We searched Medline and Embase from their inceptions with the assistance of an experienced librarian. All abstracts and complete articles were independently reviewed by two reviewers, according to predefined inclusion criteria. Six hundred forty-eight abstracts were identified, and 30 complete articles were read in full. Three articles with a total of 575 participating women met the inclusion criteria. The rate of Caesarean section with use of 80 mL Foley catheters was not significantly different from the rate using 30 mL Foley catheters (RR 0.82; 95% CI 0.48 to 1.41). A favourable cervix (which was defined heterogeneously) was more common with high volume catheters (RR 1.72; 95% CI 1.46 to 2.04), and failure to deliver in 24 hours was lower (RR 0.70; 95% CI 0.54 to 0.90). High volume Foley catheters improve the likelihood of a favourable cervix and chance of delivery in 24 hours more than low volume Foley catheters. As a more favourable cervix before induction of labour is associated with a lower rate of Caesarean section, a randomized controlled trial comparing high and low volume Foley catheters for cervical ripening using Caesarean section as the primary outcome is warranted.

La maturation cervicale au moyen d'une sonde de Foley avant le déclenchement du travail constitue une intervention obstétricale courante. Dans le cadre de cette étude, nous avons en premier lieu cherché à évaluer la relation entre la césarienne et l'utilisation de sondes de Foley de volume élevé ou faible aux fins de la maturation cervicale, pour ensuite chercher à évaluer la relation entre le volume de la sonde de Foley, la maturité cervicale et le délai avant l'accouchement. Nous avons mené des recherches dans Medline et Embase pour la période allant de leur mise en œuvre jusqu'au 22 octobre 2013, avec l'aide d'un bibliothécaire expérimenté. Tous les résumés et les articles intégraux ont fait l'objet d'une analyse indépendante menée par deux analystes, conformément à des critères d'inclusion prédéfinis. Six cent quarante-huit résumés ont été identifiés et 30 articles intégraux ont été lus au complet. Trois de ces articles (comptant un nombre total de 575 participantes) ont satisfait aux critères d'inclusion. Aucune différence significative n'a été constatée entre le taux de césarienne associé à l'utilisation de sondes de Foley de 80 ml et celui qui était associé à l'utilisation de sondes de Foley de 30 ml (RR, 0,82; IC à 95 %, 0,48 - 1,41). La présence d'un col favorable (concept dont la définition était hétérogène) était plus courante dans le cas des sondes de volume élevé (RR, 1,72; IC à 95 %, 1,46 - 2,04), tandis que l'incapacité de procéder à l'accouchement dans les 24 heures était moindre (RR, 0,70; IC à 95 %, 0,54 - 0,90). Les sondes de Foley de volume élevé sont associées à une meilleure amélioration de la probabilité d'obtenir un col favorable et de procéder à l'accouchement dans les 24 heures que celle que permettent les sondes de Foley de faible volume. Puisque la présence d'un col plus favorable avant le déclenchement du travail est associée à un taux moindre de césarienne, la tenue d'un essai randomisé comparant l'utilisation de sondes de Foley de volume élevé à celle de sondes de faible volume aux fins de la maturation cervicale (en utilisant la césarienne à titre de critère d'évaluation principal) s'avère justifiée.

Fetal movement monitoring: how are we doing as educators?

OBJECTIVE: When decreased fetal movement is noticed, delay in seeking care is associated with poor perinatal outcomes, including stillbirth. Health care providers are responsible for educating women about normal fetal movement and the appropriate actions they should take if it decreases. This study aimed to demonstrate our pregnant population's understanding of normal fetal movement and responses to decreased fetal movement, and to potentially guide educational interventions to improve perinatal outcomes. METHODS: We surveyed 304 pregnant women (over 26 weeks' gestation) during clinic visits at the IWK Health Centre, Halifax, NS. Information collected in the survey included demographics, knowledge about normal fetal movement, monitoring techniques, and response to decreased fetal movement. RESULTS: Eighteen percent of women (55/298) demonstrated knowledge of normal fetal movement and fetal monitoring, indicating that they would seek assessment promptly if they experienced decreased fetal movement. Although 54.7% of participants (164/300) would contact a health care professional if they noticed decreased fetal movement, approximately two thirds of participants were unable to describe normal fetal movement or monitoring techniques. Almost 30% of participants (90/304) did not identify daily fetal movement as normal, and 37.5% (114/304) reported it may be normal for fetal movement to stop around their due date. Written and verbal communication regarding fetal movement from a health care provider significantly increased the likelihood of appropriate intended self-management in the context of decreased fetal movement. CONCLUSION: Education influences the anticipated behaviour of pregnant women regarding decreased fetal movement. Specific areas of misinformation which may guide future education strategies are identified. There is room for improvement in this area of patient education.

VTE prophylaxis in pregnant people with chronic physical disability: Data from a physicians survey and the need for guidance.

Background: International guidelines recommend risk assessment during the antepartum and postpartum period to inform VTE prophylaxis. We aimed to evaluate physicians' approach to VTE prophylaxis of women with chronic physical disability (CPD) during pregnancy. Methods: A cross-sectional study consisting of a self-administered electronic questionnaire was sent to specialists across Canada. Results: Seventy-three participants responded to the survey, and 55 (75.3%) completed the survey including 33 (60%) Maternal Fetal Medicine (MFM) specialists and 22 (40%) Internal Medicine (IM) specialists including physicians with an interest in Obstetric Medicine. Our study shows considerable variation in VTE thromboprophylaxis during pregnancy with CPD. Most respondents favoured antepartum (67.3%) and postpartum (65.5%) VTE prophylaxis for pregnancies within a year of spinal cord injury. Conclusions: In order to better manage this complex population, CPD should be considered as a risk factor for development of VTE.

Preterm birth risk in women with skeletal dysplasias and short stature.

PURPOSE: The primary objective was to estimate the risk of preterm delivery in a population of women with a skeletal dysplasia and short stature. The secondary outcome was to identify factors that increase the risk of preterm delivery. METHODS: A cross sectional survey was performed asking detailed pregnancy and reproductive health questions, aimed at a convenience sample of women who were little people, administered through Little People of America, Little People UK, Little People Canada, and the World Dwarf Games. Comparisons were made on gestational age at delivery between pregnancies with and without the outcomes. RESULTS: The survey had a response rate of 74% (117/158). There was a total of 55 eligible subjects who had 72 live births. Delivery prior to 37 weeks occurred in 19/72 live births, which equates to a preterm birth rate of 26.4%. Besides short stature, no single factor was identified that could solely explain the elevated preterm birth risk in the study population. CONCLUSION: The risk of preterm delivery in women with skeletal dysplasias and short stature is elevated compared to the general population. This information will assist healthcare providers in pregnancy management and counseling.

Reproductive health and pregnancy experiences of women with spina bifida: A qualitative study.

PURPOSE: Despite an increasing number of individuals with spina bifida reaching reproductive age, there has been a paucity of research into their reproductive health care needs. The objective of this study was to better understand the reproductive health experiences of self-identified women with spina bifida using qualitative methodology. METHODS: A phenomenological study design was used to address this objective. Women with spina bifida identified their interest in participating in a semi-structured interview after completing an online reproductive health survey. Interviews were recorded and transcribed verbatim. Qualitative analysis followed a phenomenological approach using Dedoose software. RESULTS: Twelve self-identified women with spina bifida participated. They described experiences in four domains: sexual education, pregnancy, labor and delivery, and postpartum. In addition, an intersecting domain of social justice and advocacy emerged. Numerous themes are described, including a lack of tailored sexual health information, impact of pregnancy on function, attitudes towards delivery method, and parenting challenges. CONCLUSION: This study explored the continuum of reproductive health experiences of women with spina bifida. They face unique reproductive health challenges that provide an opportunity for health care providers to offer more holistic care.

Women's health guidelines for the care of people with spina bifida.

Women and girls with spina bifida have specific health care concerns. It is essential that they, and their health care providers have access to information to help them make healthy choices throughout their lifespan. This article aims to address key aspects of health pertinent to girls and women with spina bifida and outlines the SB Women's Health Guidelines for the Care of People with Spina Bifida. Further research into this area is needed.

Prenatal counseling: Guidelines for the care of people with spina bifida.

As the diagnosis of Spina Bifida (SB) is often made prenatally, SB-specific prenatal counseling is needed. It is essential to provide information about medical care and lifelong impact of this diagnosis, treatment options available to women carrying fetuses affected, and resources that will assist in the care of individuals with SB. This article outlines the SB Prenatal Counseling Guidelines from the 2018 Spina Bifida Association's Fourth Edition of the Guidelines for the Care of People with Spina Bifida and acknowledges that further research in SB prenatal counseling is warranted.

Women with physical disability in pregnancy resident education: a national survey as a needs assessment for curriculum improvement in obstetrics and gynaecology in Canada.

OBJECTIVES: To explore the current status to which Canadian obstetrics and gynaecology (Ob-Gyn) programmes teach residents about pregnancy in patients with physical disabilities, and to assess the level of interested in providing formal education sessions in this field. This study also assesses the residents' perception of their knowledge and their comfort level caring for women with physical disabilities (WWPD), which will further determine the need for incorporation of this topic into the residency curriculum. DESIGN: Cross-sectional survey. SETTING: All Canadian English accredited Ob-Gyn residency programmes. PARTICIPANTS: Programme directors and residents. MAIN OUTCOME MEASURES: The current self-reported education and exposure Canadian Ob-Gyn residents have surrounding WWPD in pregnancy, and if there is an interest in further education in this area. METHODS: An online survey was developed and distributed to all Canadian English accredited Ob-Gyn residency programme directors and residents. Answers were collected over a 2-month period in 2017, which consisted of an initial email and two email reminders. Questions were in three key areas: demographic characteristics, knowledge gap and level of interest in a formal method of education. RESULTS: Eighty-four residents and nine programme directors participated in the surveys. Eighty-six per cent of residents and all programme directors responded that there are no formal scheduled training sessions on WWPD as part of the residency curriculum. Two-thirds of the residents reported being uncomfortable with the management issues surrounding a woman with a disability in pregnancy. A vast majority of residents (91.67%) and all programme directors have an interest in incorporating this topic into the residency curriculum to meet the need of pregnant women with disabilities. CONCLUSIONS: This survey indicated that there is both a need for and interest in education in the area of pregnancy and physical disability in the Canadian Ob-Gyn residency programme. This information suggests that the development of educational materials in this area should be considered to address an unmet need with the ultimate goal of improving the care provided to WWPD in pregnancy. Future projects in this area should focus on content development taking into account the CanMEDS and competency-based medical education framework.

Pregnancy Outcome in Cartilage-Hair Hypoplasia, a Rare Form of Dwarfism.

Background. This case report discusses the pregnancy outcome of a patient with cartilage-hair hypoplasia, a rare form of dwarfism, and multiple previous orthopedic surgeries. Literature on pregnancy outcomes in patients with cartilage-hair hypoplasia is limited. Case. A 32-year-old patient with cartilage-hair hypoplasia presented at 12 weeks' gestation to the high-risk obstetrics clinic for care. Preterm labor resulted in cesarean delivery at 34 weeks' gestation with general anesthetic. Breastfeeding was stopped at 6 weeks due to neonatal complications. Conclusion. Pregnancy and delivery were uncomplicated. A multidisciplinary approach allowed for effective management during pregnancy and postnatal care. This is the first known documented case of prenatal care, delivery, and breastfeeding in a woman with this rare disorder.