Retrospective Cohort Study of Cervical Pessary Use in Women with Short Cervix at Risk of Preterm Delivery.

OBJECTIVE: A paucity of effective interventions exists for the prevention of preterm birth (PTB). Renewed interest has focused on cervical pessaries, which have the benefits of being inexpensive, nonsurgical, and easily inserted and removed. In this study, we aim to describe our experience with this device in a Canadian tertiary care centre. Primary outcomes were rates of spontaneous or iatrogenic PTB before 37, 34, and 28 weeks gestation in pregnancies complicated by short cervix treated with cervical pessary. METHODS: This was a retrospective cohort study of women with singleton, twin, and triplet pregnancies with pessary placement from August 2013 to March 2015 in the Urogynecology Clinic at the Lois Hole Hospital for Women in Edmonton, AB. Included women were deemed to be at high risk of PTB due to short cervix (≤25 mm) found on ultrasound. RESULTS: Among 115 women included, pessaries were placed at a mean gestation of 25.3 weeks. Forty-nine singleton women (52.7%) delivered at term. Of these deliveries, 75% were spontaneous. Rates of PTB before 34 and 28 weeks gestation for all deliveries, respectively, were 37.4% and 10.4%. Removal data were available for 87.8% of patients, and the pessary remained in situ for a mean of 48 days. CONCLUSION: In this study's high-risk obstetrical population, the rates of preterm birth remained high. The effectiveness of pessary use, particularly when compared to other preventative strategies, remains a topic in need of further investigation. To our knowledge, this is the first study to contribute pessary data from a Canadian population.

Accuracy of Prenatal Ultrasound in Detecting Growth Abnormalities in Triplets: A Retrospective Cohort Study.

Significant management decisions in triplet pregnancies are made based mainly on ultrasound measurements of fetal growth, although there is a paucity of data examining the accuracy of fetal weight measurements in these gestations. To evaluate accuracy of prenatal ultrasound to diagnose growth abnormalities (intrauterine growth restriction, severe growth discordance) in triplet pregnancies, a retrospective cohort study of 78 triplet pregnancies (234 fetuses) delivered at a single tertiary hospital from January 2004 to May 2015 was performed. Growth percentiles from the last ultrasound were derived from estimated fetal weight using Hadlock's formula for each triplet. Growth discordance was calculated for each triplet set using the formula {(estimated fetal weight largest triplet - estimated fetal weight smallest)/estimated fetal weight largest}. These estimations were compared to birth weights. Sensitivity of ultrasound to predict ≥1 growth restricted fetus in a triplet set was 55.6% [95% CI 35.3, 74.5]; specificity was 100% [95% CI 93.0, 100]; positive predictive value (PPV) 100% [95% CI 74.7, 100]; negative predictive value (NPV) 81.0% [95% CI 73.2, 85.7%]. Sensitivity of ultrasound to detect fetal growth discordance >25% in a triplet set was 80.0% [95% CI 44.4, 97.5], specificity 94.1% [95% CI 85.6, 98.4]; PPV 66.7% [95% CI 42.4, 84.5]; NPV 97.0% [95% CI 90.2, 99.1]. Prenatal ultrasound currently remains the most reliable tool to screen for growth anomalies in triplet pregnancies; however, it appears to have less than ideal sensitivity, missing a number of cases of intra-uterine growth restriction and significant growth discordance.

Amniotic Fluid: Technical Update on Physiology and Measurement.

OBJECTIVE: OUTCOMES: EVIDENCE: A MEDLINE and KFINDER search was used to identify relevant articles, with review of bibliography identified article including Cochrane reviews and recent review articles. VALUES: The evidence collected was reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynecologists of Canada. The recommendations were made according to the guidelines developed by The Canadian Task Force on Preventative Health Care (Table 1). BENEFITS, HARMS AND COSTS: Amniotic fluid assessment by ultrasound has become an integral part of fetal assessment in modern obstetrics. Abnormalities of fluid volume result in obstetrical intervention and further investigations. In Canada, there are no standard definitions of fluid volume estimation, nor a standard approach to assessing fluid. Multiple randomized trials have suggested that using a Single Pocket Estimation technique (rather than the multi pocket assessment approach known as the amniotic fluid index), will result in fewer obstetrical interventions without any increase in adverse outcomes. Recent literature suggests that there are detectable, modest changes in amniotic fluid that can occur within an hour or two of normal physiological maneuvers. This may account for the variability and inconsistent results from repeated assessments within a short period of time which can lead to confusion and generate further testing. This article hopes to describe the limitations of amniotic fluid assessment, promote a standard method of amniotic fluid assessment, and propose a common set of definitions to be used to describe amniotic fluid volume. SUMMARY STATEMENTS: RECOMMENDATION.

Mise à jour technique sur la physiologie et l'évaluation du liquide amniotique.

OBJECTIF: RéSULTATS: SOURCES DES DONNéES PROBANTES: Nous avons effectué une recherche sur MEDLINE et Kfinder pour trouver des articles pertinents, puis avons examiné les bibliographies des articles retenus, notamment des revues Cochrane et des articles de revue récents. VALEURS: Les données recueillies ont été analysées par le Comité d'imagerie diagnostique de la Société des obstétriciens et gynécologues du Canada. Les recommandations ont été classées selon les critères établis par le Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). AVANTAGES, DéSAVANTAGES ET COûTS: En obstétrique moderne, l'évaluation du volume de liquide amniotique par échographie fait partie intégrante de l'évaluation fœtale. Toute anomalie donne lieu à une intervention obstétricale et à des examens approfondis. Au Canada, il n'existe aucune définition normalisée associée à l'estimation du volume de liquide amniotique ni aucune approche d'évaluation uniforme. Plusieurs essais randomisés semblent indiquer que l'évaluation de poche unique, plutôt que de plusieurs poches (indice de liquide amniotique), diminue les interventions obstétricales sans augmenter l'incidence de résultats indésirables. La littérature récente laisse croire que des changements légers, mais détectables du liquide amniotique peuvent survenir une heure ou deux suivant des manœuvres physiologiques normales, ce qui pourrait expliquer la variabilité et le manque de cohérence des résultats d'évaluations répétées en peu de temps et ainsi créer de la confusion et donner lieu à d'autres examens. Le présent article vise à décrire les limites de l'évaluation du volume de liquide amniotique, à promouvoir une méthode d'évaluation normalisée et à proposer un ensemble commun de définitions. DéCLARATIONS SOMMAIRES: RECOMMANDATION.

A Woman With Marfan Syndrome in Pregnancy: Managing High Vascular Risk With Multidisciplinary Care.

BACKGROUND: Women with connective tissue disorders are at risk for cardiovascular complications during pregnancy, but there are no guidelines for pregnant women with aortic root diameter>45 mm or with rapid aortic widening. We describe the issues of practical significance in the management of pregnancy and delivery in a woman with Marfan syndrome (MFS). CASE: A pregnant woman with MFS presented for tertiary care at 26 weeks' gestation. Rapid aortic dilatation triggered a decision to undertake delivery preterm, with a resulting good neonatal outcome. A multidisciplinary approach aided in optimizing the monitoring and timing of delivery and subsequent aortic repair, and allowed planning for the management of a potential vascular catastrophe. CONCLUSION: Having optimal maternal and neonatal outcomes for pregnant women with Marfan syndrome depends on a highly responsive and coordinated team effort, including meticulous planning for a vascular catastrophe.

Contexte : Bien que les femmes qui présentent des troubles affectant les tissus conjonctifs soient exposées à des risques de complications cardiovasculaires pendant la grossesse, nous ne disposons d'aucune ligne directrice en ce qui concerne les femmes enceintes dont le diamètre de l'anneau aortique est supérieur à 45 mm ou qui connaissent un élargissement rapide de l'aorte. Nous décrivons les facteurs significatifs sur le plan pratique dans le cadre de la prise en charge de la grossesse et de l'accouchement chez une femme atteinte du syndrome de Marfan.  Cas : Une femme enceinte atteinte du syndrome de Marfan nous a consultés pour obtenir des soins tertiaires à 26 semaines de gestation. La dilatation rapide de l'aorte a mené à la décision de procéder à un accouchement préterme (lequel a donné lieu à une bonne issue néonatale). Le recours à une approche multidisciplinaire a contribué à l'optimisation du monitorage et de la chronologie de l'accouchement (et à la réparation subséquente de l'aorte), en plus de permettre la planification de la prise en charge d'une potentielle catastrophe vasculaire.  Conclusion : Dans le cas des femmes enceintes qui sont atteintes du syndrome de Marfan, l'obtention d'issues maternelles et néonatales optimales dépend de la mise en œuvre d'un effort d'équipe grandement attentif et coordonné (y compris celle d'une planification méticuleuse de la prise en charge d'une potentielle catastrophe vasculaire).

Triplet pregnancy: is the mode of conception related to perinatal outcomes?

Many triplets are conceived as a consequence of assisted reproductive technology (ART). Concerns have been raised that triplet pregnancies conceived by ART are more complicated than those conceived spontaneously. The purpose of this study was to evaluate all triplet pregnancies managed over a 12-year period to determine if there were any differences in outcome based on the mode of conception. All triplet pregnancies between 1999 and 2011 that reached at least 20 weeks' gestation and that were managed at the Royal Women's Hospital (RWH), Melbourne, Victoria were identified. Maternal and neonatal outcomes were compared between ART conceived and spontaneously conceived triplets. In the study period, 53 sets of triplets managed in our institution met the eligibility criteria. Twenty-five triplet sets were conceived by ART and 28 were conceived spontaneously. More ART conceptions resulted in trichorionic triamniotic (TCTA) triplets than did spontaneous conceptions (p = .015). There were no differences between ART and spontaneously conceived triplets for any of the maternal or neonatal complications studied. Trichorionic (TC) triplets delivered at a later gestation than other triplets: 32.1 (SD 2.9) versus 30.4 (SD 3.9) weeks (p = .08). TC triplets were significantly less likely to die than monochorionic (MC) or dichorionic (DC) triplets: 3/93 (3%) versus 13/66 (20%) (p = .025). In conclusion, triplets conceived by ART are more likely to have TCTA placentation and TCTA triplet sets had lower mortality rates than other triplet combinations. Outcomes for triplets conceived by ART were similar to those of triplets conceived spontaneously.

RETIRED: The use of magnetic resonance imaging in the obstetric patient.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Ce document a été archivé, car il contient des informations périmées. Il ne devrait pas être consulté pour un usage clinique, mais uniquement pour des recherches historiques. Veuillez consulter le site web du journal pour les directives les plus récentes.

Is sleep disturbed in pregnancy?

OBJECTIVE: To assess features of sleep among pregnant women. METHODS: We conducted a prospective cohort study of low-risk pregnant women in a tertiary perinatal centre (CHUS) in Eastern Townships, Quebec. Sleep was assessed during the second trimester (mean gestational age 16.1 +/- 3.0 weeks) (T2) and third trimester (mean gestational age 27.5 +/- 1.8 weeks) (T3) using a validated self-administered questionnaire, the Pittsburgh Sleep Quality Index (PSQI). Scores in this index range from 0 to 21, representing the cumulative scoring of seven sleep components. Subjects with a score > 5 were identified as "poor sleepers." Descriptive, bivariate, and regression analyses were performed. RESULTS: Among 260 consenting women, 192 (73.6%) had a term delivery without any adverse outcome. There were no differences in sleep parameters between pregnancies with adverse outcome and without adverse outcome. Mean overall PSQI scores showed evidence of deterioration in sleep quality from T2 (5.26 +/- 3.16) to T3 (6.73 +/- 4.02; P < 0.01). This deterioration was displayed in five of seven sleep components (P < 0.01). Scores in the "poor sleeper" range were recorded by 36% of women in T2 and 56%, of women in T3 (P < 0.01). "Poor sleep" in T2 and T3 was associated with low or high weight gain (P < 0.01), annual family income < $40,000 (P = 0.03), and single motherhood (P < 0.01). There was a trend for a seasonal influence on sleep scores (P = 0.08). The only predictor of poor sleep using multivariate analysis was single motherhood (P < 0.01). CONCLUSION: Sleep is disturbed in early pregnancy and is worse in the third trimester. Interventions to improve sleep should be sought to optimize quality of life for pregnant women.