Gestational weight loss and fetal growth in uncomplicated pregnancies among women with obesity: a population-based retrospective cohort study.

OBJECTIVE: The impact of gestational weight loss (GWL) on fetal growth among women with obesity remains unclear. This study aimed to examine the association between weight loss during pregnancy among women with body mass index (BMI) ≥ 30 kg/m2 and the risk of small-for-gestational-age (SGA) and large-for-gestational-age (LGA) neonates. METHODS: We conducted a retrospective, population-based cohort study of women with pre-pregnancy obesity that resulted in a singleton live birth in 2012-2017, using birth registry data in Ontario, Canada. Women with pregnancy complications or health conditions which could cause weight loss were excluded. GWL is defined as negative gestational weight change (≤0 kg). The association between GWL and fetal growth was estimated using generalized estimating equation models and restricted cubic spline regression analysis. Stratified analysis was conducted by obesity class (I:30-34.9 kg/m2, II:35-39.9 kg/m2, and III + : ≥40 kg/m2). RESULTS: Of the 52,153 eligible women who entered pregnancy with a BMI ≥ 30 kg/m2, 5.3% had GWL. Compared to adequate gestational weight gain, GWL was associated with an increased risk of SGA neonates (aRR:1.45, 95% CI: 1.30-1.60) and a decreased risk of LGA neonates (aRR: 0.81, 95% CI:0.73-0.93). Non-linear L-shaped associations were observed between gestational weight change and SGA neonates, with an increased risk of SGA observed with increased GWL. On the contrary, non-linear S-shaped associations were observed between gestational weight change and LGA neonates, with a decreased risk of LGA observed with increased GWL. Similar findings were observed from the stratified analysis by obesity class. CONCLUSION: These findings highlight that GWL in women with obesity may increase the risk of SGA neonates but reduce the risk of LGA neonates. Recommendations of GWL for women with obesity should be interpreted with caution.

Screening for postpartum depression and risk of suicidality with obstetrical patients: a cross-sectional survey.

BACKGROUND: Pregnancy is a vulnerable time where the physical and social stress of the COVID-19 pandemic affects psychological health, including postpartum depression (PPD). This study is designed to estimate the prevalence and correlates of PPD and risk of suicidality among individuals who gave birth during the COVID-19 pandemic. METHODS: We surveyed individuals who gave birth at The Ottawa Hospital and were ≥ 20 days postpartum, between March 17 and June 16, 2020. A PPD screen consisted of a score ≥ 13 using the Edinburgh Postnatal Depression Scale. A score of 1, 2, or 3 on item 10 ("The thought of harming myself has occurred to me") indicates risk of suicidality. If a participant scores greater than ≥ 13 or ≥ 1 on item 10 they were flagged for PPD, the Principal Investigator (DEC) was notified within 24 h of survey completion for a chart review and to assure follow-up. Modified Poisson multivariable regression models were used to identify factors associated with PPD and risk of suicidality using adjusted risk ratios (aRR) and 95% confidence intervals (CI). RESULTS: Of the 216 respondents, 64 (30%) screened positive for PPD and 17 (8%) screened positive for risk of suicidality. The maternal median age of the total sample was 33 years (IQR: 30-36) and the infant median age at the time of the survey was 76 days (IQR: 66-90). Most participants reported some form of positive coping strategies during the pandemic (97%) (e.g. connecting with friends and family, exercising, getting professional help) and 139 (64%) reported negative coping patterns (e.g. over/under eating, sleep problems). In total, 47 (22%) had pre-pregnancy anxiety and/or depression. Negative coping (aRR:2.90, 95% CI: 1.56-5.37) and pre-existing anxiety/depression (aRR:2.03, 95% CI:1.32-3.11) were associated with PPD. Pre-existing anxiety/depression (aRR:3.16, 95% CI:1.28-7.81) was associated with risk of suicidality. CONCLUSIONS: Almost a third of participants in this study screened positive for PPD and 8% for risk of suicidality. Mental health screening and techniques to foster positive coping skills/strategies are important areas to optimize postpartum mental health.

Interventions for intimate partner violence during the perinatal period: a scoping review protocol.

INTRODUCTION: Globally, the prevalence and incidence of perinatal intimate partner violence (IPV) are well documented and substantiated; however, there is an urgent need to identify interventions to prevent recurrence or revictimisation, and decrease the harms of perinatal IPV. This scoping review is designed to broadly capture all potential interventions for the secondary prevention of IPV, review them in detail, and assess what can reduce revictimisation and foster improvements in both maternal and neonatal outcomes. METHODS AND ANALYSIS: With the structure of the Joanna Briggs Institute and Arksey and O'Malley methodology for scoping reviews, the search will be conducted in: MEDLINE(R) ALL (OvidSP), Embase (OvidSP), CINAHL (EBSCOHost), APA PsycInfo (OvidSP), Cochrane Central Register of Controlled Trials (OvidSP), Web of Science, and Applied Social Sciences Index & Abstracts (ProQuest). A manual search of the reference lists of the retrieved articles will be conducted to capture all relevant studies for potential inclusion. A year limit of January 2000-June 2022 will be applied to retrieve most current peer-reviewed articles. No search filters or language limits will be used, but only publications in English and French will be eligible for inclusion. Interventions include but are not limited to: psychotherapy, educational sessions, home visitation, etc. Outcomes include but are not limited to: (1) harms of IPV among survivors (eg, revictimisation) and (2) adverse perinatal outcomes (eg, preterm birth). Interventions will be excluded if they target the perpetrator or child(ren) alone. Titles and abstracts of included studies will be screened in duplicate. Full-text documents will be extracted and reviewed by two independent reviewers. Conflicts between reviewers will be resolved by a third independent reviewer. Findings will be presented with descriptive statistics and narrative synthesis. ETHICS AND DISSEMINATION: Ethics approval is not required for this scoping review. The results will be disseminated through peer-reviewed publication and conference presentations. STUDY REGISTRATION: Open Science Framework (OSF) registry (https://osf.io/e294r) in Centre for Open Science (OSF) on 27 May 2022.

Persisting risk factors for preeclampsia among high-risk pregnancies already using prophylactic aspirin: a multi-country retrospective investigation.

BACKGROUND: Low-dose aspirin is recommended for pregnant individuals at high-risk of developing preeclampsia, but less is known about those that develop preeclampsia even while using prophylactic aspirin for preeclampsia prevention as the best course of treatment. OBJECTIVES: The objective of this study is to investigate the risk factors with the highest risk of developing preeclampsia among pregnant individuals already using aspirin from high-risk obstetrical centers across five countries. DESIGN: This is a secondary analysis of pregnant individuals from the Folic Acid Clinical Trial (FACT) who were using prophylactic aspirin before 16 weeks gestation. The FACT randomized control trial took place in 70 high risk obstetrical centers in Canada, United Kingdom, Australia, Jamaica, and Argentina between 2011-2015. Participants were included if they had any of the risk factors for preeclampsia: diabetes, chronic hypertension, twin pregnancy, history of preeclampsia, and/or obesity (Body Mass Index ≥35). The outcomes of interest were preeclampsia and preterm preeclampsia (<37 weeks). Log binomial regressions assessed factors significantly associated with any preeclampsia or preterm-preeclampsia (<37 weeks) using adjusted risk ratios (ARR) and 95% confidence intervals (CI). RESULTS: There were 2296 pregnant individuals with complete information on aspirin included in this study. At baseline, all patients were at high risk of preeclampsia and were eligible for aspirin prophylaxis, however, only 660 (28.7%) were taking aspirin. Among the 660 pregnant individuals taking aspirin, 132 (20%) developed preeclampsia and 60 (9.09%) preterm preeclampsia. Among pregnant individuals using aspirin, the risks of preeclampsia were highest for twins (ARR:2.62, 95% CI: 1.68-4.11), history of preeclampsia (ARR: 2.42, 95% CI: 1.74-3.38), and hypertension (ARR:1.92, 95% CI: 1.37-2.69). Similar trends were found for preterm-preeclampsia for twins (ARR:4.10, 95% CI:2.15-7.82), history of preeclampsia (ARR:2.75, 95% CI:1.62-4.67), and hypertension (ARR:2.18, 95% CI:1.28-3.72). No significant differences were found for obesity or diabetes. CONCLUSION: These findings suggest that individuals with twin pregnancies, a history of preeclampsia, or hypertension may not benefit from aspirin to the same extent as those with other complications such as obesity or diabetes. Careful clinical monitoring for these risks factors is recommended and future research into the effectiveness in these populations would increase our understanding of the current best practice of prophylactic aspirin use to prevent preeclampsia. TRIAL REGISTRATION: Current Controlled Trials ISRCTN23781770 and ClinicalTrials.gov NCT01355159.

Use of tranexamic acid (TXA) to reduce preterm birth and other adverse obstetrical outcomes among pregnant individuals with placenta previa: a systematic review protocol.

INTRODUCTION: Placenta previa is a placental implantation pathology where the placenta overlies the internal endocervical os. Placenta previa affects approximately 4 per 1000 pregnancies and increases the risk of antepartum bleeding, emergent preterm labour and emergency caesarean sections. Currently, placenta previa is managed through expectant management. Guidelines primarily revolve around the mode and timing of delivery, in-hospital admissions and surveillance. However, the methods to prolong pregnancy have not proven to be clinically effective. Tranexamic acid (TXA), an antifibrinolytic agent, is effectively used to prevent and treat postpartum haemorrhage as well as menorrhagia, with limited adverse effect, and may prove to be an effective treatment for placenta previa. The objective of this systematic review protocol is to review and synthesise the evidence of TXA use for antepartum haemorrhage in placenta previa. METHODS AND ANALYSIS: Preliminary searches were conducted on 12 July 2022. We will search MEDLINE, EMBASE, CINAHL, Scopus and the Cochrane Central Register of Controlled Trials. Grey literature resources such as clinical trials registries (ClinicalTrials.gov and the WHO's International Clinical Trials Registry) and preprint servers (Europe PMC and Open Science Framework) will also be searched. The search terms will comprise of index headings and keyword searches related to TXA and the placenta or antepartum bleeding. Cohort and randomised and non-randomised trials will be considered. The target population is pregnant people, of any age, with placenta previa. The intervention is TXA given in the antepartum period. The main outcome of interest is preterm birth before 37 weeks, however, all perinatal outcomes will be collected. Title and abstract will be screened by two reviewers and any conflict will be discussed and evaluated by a third reviewer. The literature will be summarised in narrative form. ETHICS AND DISSEMINATION: No ethics approval is required for this protocol. Findings will be disseminated through peer-review publication, lay summaries and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42022363009).

Population-Level Trends in Emergency Department Encounters for Sexual Assault Preceding and During the COVID-19 Pandemic Across Ontario, Canada.

Importance: Lockdown measures and the stress of the COVID-19 pandemic are factors associated with increased risk of violence, yet there is limited information on trends in emergency department (ED) encounters for sexual assault. Objective: To compare changes in ED encounters for sexual assault during the COVID-19 pandemic vs prepandemic estimates. Design, Setting, and Participants: This retrospective, population-based cohort study used linked health administrative data from 197 EDs across Ontario, Canada, representing more than 15 million residents. Participants included all patients who presented to an ED in Ontario from January 11, 2019, to September 10, 2021. Male and female individuals of all ages were included. Data analysis was performed from March to October 2022. Exposures: Sexual assault, defined through 27 International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, procedure and diagnoses codes. Main Outcomes and Measures: Ten bimonthly time periods were used to compare differences in the frequency and rates of ED encounters for sexual assault between 2020 to 2021 (during the pandemic) compared with baseline prepandemic rates in 2019. Rate differences (RDs) and age adjusted rate ratios (aRRs) and Wald 95% CIs were calculated using Poisson regression. Results: From January 11, 2019, to September 10, 2021, there were 14 476 656 ED encounters, including 10 523 for sexual assault (9304 [88.4%] among female individuals). The median (IQR) age was 23 (17-33) years for female individuals and 15 (4-29) years for male individuals. Two months before the pandemic, ED encounters increased for sexual assault among female individuals (8.4 vs 6.9 cases per 100 000; RD, 1.51 [95% CI, 1.06 to 1.96]; aRR, 1.22 [95% CI, 1.09 to 1.38]) and male individuals (1.2 vs 1.0 cases per 100 000; RD, 0.19 [95% CI, 0.05 to 0.36]; aRR, 1.19 [95% CI, 0.87 to 1.64]). During the first 2 months of the pandemic, the rates decreased for female individuals (4.2 vs 8.3 cases per 100 000; RD, -4.07 [95% CI, -4.48 to -3.67]; aRR, 0.51 [95% CI, 0.44 to 0.58]) and male individuals (0.5 vs 1.2 cases per 100 000; RD, -0.72 [95% CI, -0.86 to -0.57]; aRR, 0.39 [95% CI, 0.26 to 0.58]). For the remainder of the study period, the rates of sexual assault oscillated, returning to prepandemic levels during the summer months and between COVID-19 waves. Conclusions and Relevance: These findings suggest that lockdown protocols should evaluate the impact of limited care for sexual assault. Survivors should still present to EDs, especially when clinical care or legal interventions are needed.

Worries, beliefs and factors influencing perinatal COVID-19 vaccination: a cross-sectional survey of preconception, pregnant and lactating individuals.

BACKGROUND: COVID-19 vaccines are recommended for pregnant and lactating individuals, and there is substantial evidence for their safety and effectiveness. As the pandemic continues, information on worries and beliefs surrounding perinatal COVID-19 vaccination remains important to inform efforts aimed at improving vaccine uptake. Our objectives were to assess factors associated with COVID-19 vaccination among perinatal individuals; and to explore motivational factors associated with willingness to be vaccinated among unvaccinated perinatal individuals. METHODS: This was a cross-sectional web-based survey of preconception, pregnant, and lactating individuals in Canada. The outcomes of interest were vaccination with at least one dose of any COVID-19 vaccine and willingness to be vaccinated among unvaccinated individuals. Sample characteristics were summarized using frequencies and percentages. The association between eight prespecified risk factors and two outcomes (vaccination status and willingness to be vaccinated) was assessed by logistic regression. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for the total sample, and across perinatal sub-groups. RESULTS: Among 3446 survey respondents, there were 447 (13.0%) preconception, 1832 (53.2%) pregnant, and 1167 (42.4%) lactating. There were 1460 (42.4%) and 1982 (57.5%) who were vaccinated and unvaccinated, respectively. Factors positively associated with COVID-19 vaccine status were speaking to a healthcare provider about vaccination during the perinatal period (aOR:2.35, 95% CI:1.97-2.80) and believing that the COVID-19 vaccine is effective (aOR:1.91, 95% CI:1.46-2.48). Factors negatively associated with vaccine status included worries about fetal growth and development (aOR:0.55, 95% CI:0.43-0.70) and future child behavioral/neurodevelopmental problems (aOR:0.59, 95% CI:0.46-0.75). Among unvaccinated individuals specifically, characteristics positively associated with willingness to vaccinate were speaking to a healthcare provider (aOR:1.67, 95% CI:1.32-2.12) and believing the COVID-19 vaccine is effective (aOR:3.56, 95% CI:2.70-4.69). Factors negatively associated with willingness were concerns over infertility (aOR:0.66, 95% CI:0.49-0.88), fetal growth and development (aOR:0.33, 95% CI:0.24-0.46), and future child behavioral/neurodevelopmental problems (aOR:0.64, 95% CI:0.48-0.84). CONCLUSIONS: In this Canadian perinatal population, approximately 42% reported COVID-19 vaccination. Among unvaccinated individuals, willingness to receive vaccination was high (73%). Factors enhancing vaccine willingness included discussions with healthcare providers and believing the vaccine was effective. Concerns regarding vaccine safety, particularly with respect to fetal/child development, were the greatest barriers to vaccine uptake.

A randomized control trial of high-dose micronutrient-antioxidant supplementation in healthy persons with untreated HIV infection.

BACKGROUND: Although micronutrient and antioxidant supplementation are widely used by persons with human immunodeficiency virus (HIV), a therapeutic role beyond recommended daily allowances (RDA) remains unproven. An oral high-dose micronutrient and antioxidant supplement (Treatment) was compared to an RDA supplement (Control) for time to progressive immunodeficiency or initiation of antiretroviral therapy (ART) in people living with HIV (PLWH). METHODS: This study was a randomized, double-blind, placebo-controlled multicenter clinical trial. PLWH were recruited from Canadian HIV Trials Network sites, and followed quarterly for two years. Eligible participants were asymptomatic, antiretroviral treatment (ART)-naïve, HIV-seropositive adults with a CD4 T lymphocyte count (CD4 count) between 375-750 cells/µL. Participants were randomly allocated 1:1 to receive Treatment or Control supplements. The primary outcome was a composite of time-to-first of confirmed CD4 count below 350 cells/µL, initiation of ART, AIDS-defining illness or death. Primary analysis was by intention-to-treat. Secondary outcomes included CD4 count trajectory from baseline to ART initiation or two years. A Data and Safety Monitoring Board reviewed the study for safety, recruitment and protocol adherence every six months. RESULTS: Of 171 enrolled participants: 66 (38.6%) experienced a primary outcome: 27 reached a CD4 count below 350 cells/µL, and 57 started ART. There was no significant difference in time-to-first outcome between groups (Hazard Ratio = 1.05; 95%CI: 0.65, 1.70), or in time to any component outcome. Using intent-to-treat censoring, mean annualized rates of CD4 count decline were -42.703 cells/µL and -79.763 cells/µL for Treatment and Control groups, with no statistical difference in the mean change between groups (-37.06 cells/µL/52 weeks, 95%CI: (-93.59, 19.47); p = 0.1993). Accrual was stopped at 171 of the 212 intended participants after an interim analysis for futility, although participant follow-up was completed. CONCLUSIONS: In ART-naïve PLWH, high-dose antioxidant, micronutrient supplementation compared to RDA supplementation had no significant effect on disease progression or ART initiation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00798772.

Giving Birth in the Early Phases of the COVID-19 Pandemic: The Patient Experience.

OBJECTIVE: Obstetrical patients are at risk of complications from COVID-19 and face increased stress due to the pandemic and changes in hospital birth setting. The objective was to describe the perinatal care experiences of obstetrical patients who gave birth during the early phases of the COVID-19 pandemic. METHODS: A descriptive epidemiological survey was administered to consenting patients who gave birth at The Ottawa Hospital (TOH) between March 16th and June 16th, 2020. The participants reported on prenatal, in-hospital, and postpartum care experiences. COVID-19 pandemic related household stress factors were investigated. Frequencies and percentages are presented for categorical variables and median and interquartile range (IQR) for continuous variables. RESULTS: A total of 216 participants were included in the analyses. Median participants age was 33 years (IQR: 30-36). Collectively, 94 (43.5%) participants felt elevated stress for prenatal appointments and 105 (48.6%) for postpartum appointments because of COVID-19. There were 108 (50.0%) were scared to go to the hospital for delivery, 97 (44.9%) wore a mask during labour and 54 (25.0%) gave birth without a support person. During postpartum care, 125 (57.9%) had phone appointments (not offered prior to COVID-19), and 18 (8.3%) received no postpartum care at all. CONCLUSION: COVID-19 pandemic and public health protocols created a stressful healthcare environment for the obstetrical population where many were fearful of accessing services, experienced changes to standard care, or no care at all. As the pandemic continues, careful attention should be given to the perinatal population to reduce stress and improve continuity of care.

RéSUMé: OBJECTIF: Les patients obstétriques sont à risque de complications de la COVID-19 et font face à un stress accru en raison de la pandémie et des changements dans le cadre de l'accouchement en milieu hospitalier. L'objectif était de décrire les expériences de soins périnataux des patients obstétriques qui ont accouché au cours des premières phases de la pandémie de COVID-19. MéTHODES: Un sondage épidémiologique descriptif a été menée auprès de patients qui ont accouché à L'Hôpital d'Ottawa (TOH) entre le 16 mars et le 16 juin 2020. Les participants ont fait un compte rendu de leurs expériences en matière de soins prénataux, hospitaliers et post-partum. Les facteurs de stress domestique liés à la COVID-19 ont été étudiés. Les fréquences et les pourcentages sont présentés pour les variables catégorielles et la médiane et l'écart interquartile (IQR) sont présentés pour les variables continues. RéSULTATS: Au total, 261 participants ont répondu au sondage. L'âge maternel médian était de 33 ans (IQR: 30­36). Collectivement, 94 participants (43,5%) ressentaient un stress élevé en lien avec les rendez-vous prénataux et 105 (48,6%) pour les rendez-vous post-partum en raison de la COVID-19. Il y avait 108 patients (50,0%) qui avaient peur d'aller à l'hôpital pour accoucher, 97 (44,9%) qui portaient un masque pendant leur travail et 54 (25,0%) qui ont accouché sans personne de soutien. En lien avec les soins post-partum, 125 (57,9%) ont eu des rendez-vous téléphoniques (non offerts avant la pandémie COVID-19) et 18 (8,3%) n'ont reçu aucun soin post-partum. CONCLUSION: La pandémie de COVID-19 et les politiques de santé publique ont créé un environnement de soins de santé stressant pour la population obstétrique où beaucoup avaient peur d'accéder aux services de soins, ont connu des changements dans les soins de base ou n'ont pas eu de soins du tout. Alors que la pandémie se poursuit, une attention particulière doit être accordée à la population périnatale afin de réduire le stress et améliorer la continuité des soins.

The psychological impact of the COVID-19 pandemic and a SARS-CoV-2 testing programme on obstetric patients and healthcare workers.

OBJECTIVES: The aim of this study was to describe the psychological impact of the COVID-19 pandemic and the specific impact of a universal SARS-CoV-2 testing programme on obstetric patients and healthcare workers at The Ottawa Hospital. METHODS: This was a follow-up survey study of obstetric healthcare workers and then-pregnant patients who participated in a SARS-CoV-2 testing programme conducted in The Ottawa Hospital obstetrical triage units from 19 October to 17 November 2020. Surveys explored the effects of the COVID-19 pandemic and the testing programme on participants' psychological well-being. Responses were collected from April to September 2021. Descriptive summary statistics were calculated for both groups. RESULTS: During hospitalization for delivery, obstetric patients (n = 143) worried about giving COVID-19 to their new baby (88.11%), catching COVID-19 (83.22%), and giving COVID-19 to their partner (76.22%). Patients felt relief at being tested for COVID-19 during the universal testing programme (24.65%) and at getting their results (28.87%). Patients also believed that universal SARS-CoV-2 testing was a good way to slow COVID-19 spread (79.72%), reduce anxiety (75.52%), and increase relief (76.22%). In addition, patients felt good about participating in research that could help others (91.61%). Among obstetric healthcare workers (n = 94), job satisfaction decreased and job stress increased during the COVID-19 pandemic. The universal testing programme led to minor increases in healthcare worker job stress and burden, particularly among nurses, but the majority (85.23%) believed it was a valuable research initiative. CONCLUSION: The COVID-19 pandemic has had a negative psychological impact on obstetric patients and healthcare workers. Universal SARS-CoV-2 testing was generally viewed favourably and may serve as an effective strategy for estimating COVID-19 prevalence without adding undue stress onto patients and healthcare workers during the pandemic.

Using deep-learning in fetal ultrasound analysis for diagnosis of cystic hygroma in the first trimester.

OBJECTIVE: To develop and internally validate a deep-learning algorithm from fetal ultrasound images for the diagnosis of cystic hygromas in the first trimester. METHODS: All first trimester ultrasound scans with a diagnosis of a cystic hygroma between 11 and 14 weeks gestation at our tertiary care centre in Ontario, Canada were studied. Ultrasound scans with normal nuchal translucency were used as controls. The dataset was partitioned with 75% of images used for model training and 25% used for model validation. Images were analyzed using a DenseNet model and the accuracy of the trained model to correctly identify cases of cystic hygroma was assessed by calculating sensitivity, specificity, and the area under the receiver-operating characteristic (ROC) curve. Gradient class activation heat maps (Grad-CAM) were generated to assess model interpretability. RESULTS: The dataset included 289 sagittal fetal ultrasound images;129 cystic hygroma cases and 160 normal NT controls. Overall model accuracy was 93% (95% CI: 88-98%), sensitivity 92% (95% CI: 79-100%), specificity 94% (95% CI: 91-96%), and the area under the ROC curve 0.94 (95% CI: 0.89-1.0). Grad-CAM heat maps demonstrated that the model predictions were driven primarily by the fetal posterior cervical area. CONCLUSIONS: Our findings demonstrate that deep-learning algorithms can achieve high accuracy in diagnostic interpretation of cystic hygroma in the first trimester, validated against expert clinical assessment.

Surviving strangulation: evaluation of non-fatal strangulation in patients presenting to a tertiary care sexual assault and partner abuse care program.

BACKGROUND: Non-fatal strangulation is a dangerous mechanism of injury among survivors of intimate partner violence and sexual assault, with inadequate evidence to guide investigation in the emergency department (ED). The primary objective is to identify the proportion of intimate partner violence and sexual assault where non-fatal strangulation occurs, and to describe the sequelae of injuries. METHODS: Health records review of patients treated at the Sexual Assault and Partner Abuse Care Program (SAPACP) and/or Trauma Program at a tertiary level hospital between January 2015 and December 2018. Eligible patients were greater than 16 years old, seen by the SAPACP or trauma team for intimate partner violence and sexual assault, and had a non-fatal strangulation injury. Data were abstracted from the standardized assessment completed by the SAPACP nurse. Descriptive statistics were used. RESULTS: We identified 209 eligible cases of non-fatal strangulation, among 1791 patient presentations to the SAPACP. Median patient age was 27 years, and 97.6% were female. Computed tomography (CT) of the head was obtained in 22.5%, and CT angiography (CTA) of the head and neck in 6.2% of cases. Eleven significant injuries were identified. Two cases of vascular abnormalities: internal carotid artery indentation with possible intramural hematoma and possible internal carotid artery dissection. Other injuries included delayed bilateral subdural hematomas, a depressed skull fracture, and six nasal fractures. CONCLUSION: We found over 10% prevalence of non-fatal strangulation in survivors of intimate partner violence and sexual assault. There was a low rate of clinically important injury on the index ED visit secondary to non-fatal strangulation. Severe injury was primarily secondary to concomitant trauma, and utilization of CTA in this cohort was low. Increased awareness is needed among ED physicians regarding the need to consider CTA head and neck.

RéSUMé: CONTEXTE: La strangulation non mortelle est un mécanisme dangereux de blessures chez les survivants de violence conjugale et d'agression sexuelle, avec des preuves insuffisantes pour guider l'enquête aux services d'urgence (SU). L'objectif principal est d'identifier la proportion de violence conjugale et d'agression sexuelle où survient un étranglement non mortel, et de décrire les séquelles des blessures. MéTHODES: Examen des dossiers médicaux des patients traités au programme de soins pour les agressions sexuelles et les abus de partenaires (SAPACP) et/ou au programme de traumatologie d'un hôpital de niveau tertiaire entre janvier 2015 et décembre 2018. Les patients éligibles avaient plus de 16 ans, étaient vus par le SAPACP ou l'équipe de traumatologie pour des violences entre partenaires intimes et des agressions sexuelles, et présentaient une blessure non mortelle par strangulation. Les données ont été extraites de l'évaluation standardisée réalisée par l'infirmière du SAPACP. Des statistiques descriptives ont été utilisées. RéSULTATS: Nous avons identifié 209 cas éligibles de strangulation non fatale, parmi les 1791 présentations de patients au SAPACP. L'âge médian des patients était de 27 ans, et 97,6 % étaient des femmes. La tomodensitométrie (TDM) de la tête était réalisée dans 22,5 % des cas, et l'angiographie TDM de la tête et du cou dans 6,2 % des cas. Onze blessures significatives ont été identifiées. Deux cas d'anomalies vasculaires : indentation de l'artère carotide interne avec possible hématome intramural et possible dissection de l'artère carotide interne. Les autres blessures comprenaient des hématomes sous-duraux bilatéraux retardés, une fracture du crâne déprimée et six fractures nasales. CONCLUSION: Nous avons constaté une prévalence de plus de 10 % de strangulation non mortelle chez les survivants de violence conjugale et d'agression sexuelle. Il y avait un faible taux de blessures cliniquement importantes lors de la visite aux urgences de référence, secondaires à une strangulation non fatale. Les lésions graves étaient principalement secondaires à des traumatismes concomitants, et le recours à l'angiographie dans cette cohorte était faible. Il est nécessaire de sensibiliser davantage les médecins des urgences à la nécessité d'envisager une angioplastie de la tête et du cou.

COVID-19 and perinatal intimate partner violence: a cross-sectional survey of pregnant and postpartum individuals in the early stages of the COVID-19 pandemic.

OBJECTIVE: The objectives of this study were to: (1) document violent and controlling behaviours within intimate partnerships during the perinatal period; and (2) determine individual, interpersonal and household-level factors influencing the risk of perinatal intimate partner violence (IPV). DESIGN: Cross-sectional survey. SETTING: The Ottawa Hospital, Department of Obstetrics and Gynecology, Ottawa, Ontario, Canada. PARTICIPANTS: Patients who gave birth at The Ottawa Hospital and were >20 days post partum between 17 March and 16 June 2020. MAIN OUTCOMES AND MEASURES: Perinatal IPV was defined as regular controlling behaviours or act-based forms of emotional/physical/sexual abuse in the 12 months before pregnancy, during pregnancy and/or post partum. Log-binomial multivariable regression models were used to compute adjusted risk ratios (aRRs) and 95% CIs to identify potential risk factors for IPV: maternal age, postpartum depression, parity, increase in partner substance use and household income. RESULTS: Among 216 participants, the median maternal age was 33 years (IQR: 30-36). In total, 52 (24.07%) reported some form of perinatal IPV, 37 (17.13%) reported regular controlling behaviour and 9 (4.17%) reported both. Household income below the municipal median was the strongest risk factor for perinatal IPV (aRR: 3.24, 95% CI: 1.87 to 5.59). There was no apparent association between maternal age (aRR: 0.99, 95% CI: 0.94 to 1.04), postpartum depression (aRR: 1.03, 95% CI: 1.00 to 1.07), nulliparity (aRR: 1.18, 95% CI: 0.71 to 1.97) or increases in partner substance use (aRR: 0.73, 95% CI: 0.42 to 1.25) with IPV. CONCLUSION: One in four individuals in this study experienced perinatal IPV. Household income was the strongest risk factor, and surprisingly, many hypothesised risk factors (eg, mental health, partner substance use, etc) were not significantly associated with perinatal IPV in this sample. This highlights the challenges in both measuring IPV and identifying individuals exposed to perinatal IPV during the high stress of the COVID-19 pandemic.

Gestational Folate and Folic Acid Intake among Women in Canada at Higher Risk of Pre-Eclampsia.

BACKGROUND: Periconceptional folic acid (FA) supplementation is recommended to prevent neural tube defects; however, the extent to which recommendations are met through dietary sources and supplements is not clear. OBJECTIVES: Our objective was to evaluate the dietary and supplemental intakes of FA in a Canadian pregnancy cohort and to determine the proportions of pregnant women exceeding the Estimated Average Requirement (EAR) and Tolerable Upper Intake Level (UL). METHODS: FACT (the Folic Acid Clinical Trial) was an international multicenter, randomized, double-blinded, placebo-controlled, phase III trial investigating FA for the prevention of pre-eclampsia in high-risk pregnancies. Participants were enrolled from Canadian sites at 8-16 weeks of gestation. Dietary and supplemental FA intake data were collected through participant interviews and FFQs at the time of FACT enrollment. Categorical data were summarized as n (%) and continuous data as median (IQR). RESULTS: This study included 1198 participants. Participants consumed 485 µg dietary folate equivalents (DFE)/d (IQR: 370-630 µg DFE/d) from dietary sources of folate and FA. Through diet alone, 43.4% of participants consumed ≥520 µg DFE/d, the EAR for pregnant individuals. Of the 91.9% of participants who consumed daily FA supplements, 0.4% consumed <400 µg FA/d and 96.0% consumed ≥1000 µg/d, the UL for FA. Median (IQR) total folate intake was 2167 µg DFE/d (2032-2325 µg DFE/d); 95.3% of participants met or exceeded the EAR from all sources, but 1069 (89.2%) participants exceeded the UL. CONCLUSIONS: The majority of participants in this Canadian pregnancy cohort did not consume the recommended amount of folate from dietary sources. However, most prenatal supplements contained 1000 µg FA, resulting in the majority of women exceeding the UL. With no additional benefit associated with FA intakes beyond the UL for most women, modification of prenatal supplement formulations may be warranted to ensure women meet but do not exceed recommended FA intakes.FACT was registered at clinicaltrials.gov as NCT01355159 and at isrctn.com as ISRCTN23781770.

Impact of high-dose folic acid supplementation in pregnancy on biomarkers of folate status and 1-carbon metabolism: An ancillary study of the Folic Acid Clinical Trial (FACT).

BACKGROUND: Periconceptional folic acid (FA) supplementation is recommended to prevent the occurrence of neural tube defects. Currently, most over-the-counter FA supplements in Canada and the United States contain 1 mg FA and some women are prescribed 5 mg FA/d. High-dose FA is hypothesized to impair 1-carbon metabolism. We aimed to determine folate and 1-carbon metabolism biomarkers in pregnant women exposed to 1 mg or 5 mg FA. OBJECTIVES: This was an ancillary study within the Folic Acid Clinical Trial (FACT), a randomized, double-blinded, placebo-controlled, phase III trial designed to assess the efficacy of high-dose FA to prevent preeclampsia. METHODS: For FACT, women were randomized at 8-16 gestational weeks to receive daily 4.0 mg FA (high dose) or placebo (low dose) plus their usual supplementation (≤1.1 mg). Women were recruited from 3 Canadian FACT centers and provided nonfasting blood samples at 24-26 gestational weeks for measurement of RBC and serum total folate, serum unmetabolized FA (UMFA), tetrahydrofolate (THF), 5-methylTHF, 5-formylTHF, 5,10-methenylTHF, and MeFox (pyrazino-s-triazine derivative of 4α-hydroxy-5-methylTHF, a 5-methylTHF oxidation product); total vitamins B-12 and B-6; and plasma total homocysteine. Group differences were determined using χ2, Fisher exact, and Wilcoxon rank-sum tests. RESULTS: Nineteen (38%) women received high-dose FA and 31 (62%) received low-dose FA. The median RBC folate concentration was 2701 (IQR: 2243-3032) nmol/L and did not differ between groups. The high-dose group had higher serum total folate (median: 148.4 nmol/L, IQR: 110.4-181.2; P = 0.007), UMFA (median: 4.6 nmol/L, IQR: 2.5-33.8; P = 0.008), and 5-methylTHF (median: 126.6 nmol/L, IQR: 98.8-158.6; P = 0.03) compared with the low-dose group (median: 122.8 nmol/L, IQR: 99.5-136.0; median: 1.9 nmol/L, IQR: 0.9-4.1; median: 108.6 nmol/L, IQR: 96.4-123.2, respectively). Other biomarkers of 1-carbon metabolism did not differ. CONCLUSIONS: High-dose FA supplementation in early pregnancy increases maternal serum folate but not RBC folate concentrations, suggesting tissue saturation. Higher UMFA concentrations in women receiving high-dose FA supplements suggest that these doses are supraphysiologic but with no evidence of altered 1-carbon metabolism.

COVID-19 pandemic and violence: rising risks and decreasing urgent care-seeking for sexual assault and domestic violence survivors.

BACKGROUND: There is little information on care-seeking patterns for sexual assault and domestic violence during the COVID-19 pandemic. The objective of this study was to examine the changes in emergency department (ED) admissions for sexual assault and domestic violence since the COVID-19 pandemic was declared. METHODS: Observational ED admissions data from The Ottawa Hospital were analyzed from March 4 to May 5 (62 days) in 2020 (COVID-19 period) and compared to the same period in 2018 (pre-COVID-19). Total and mean weekly admissions were calculated for all-cause ED admissions and for sexual and domestic violence cases. A Poisson regression (without offset term) was used to calculate the weekly case count ratio and 95% confidence intervals (CI) between the two time periods. Case characteristics were compared using chi-square tests, and percent differences were calculated. RESULTS: Compared to pre-COVID-19, total ED admissions dropped by 1111.22 cases per week (32.9% reduction), and the Sexual Assault and Domestic Violence Program cases dropped 4.66 cases per week. The weekly case count ratio for sexual assault cases was 0.47 (95% CI 0.79-0.27), equivalent of 53.49% reduction in cases, and 0.52 (95% CI 0.93-0.29), equivalent to a 48.45% reduction in physical assault cases. The characteristics of presenting cases were similar by age (median 25 years), sex (88.57% female), assault type (57.14% sexual assault, 48.57% physical assault), and location (31.43% patient's home, 40.00% assailant's home). There was a significant increase in psychological abuse (11.69% vs 28.57%) and assaults occurring outdoors (5.19% vs 22.86%). CONCLUSION: This study found a decrease in ED admissions for sexual assault and domestic violence during COVID-19, despite societal conditions that elevate risk of violence. Trends in care-seeking and assault patterns will require ongoing monitoring to inform the provision of optimal support for individuals experiencing violence, particularly as countries begin to re-open or lock-down again.

Geographies of Sexual Assault: A Spatial Analyses to Identify Neighborhoods Affected by Sexual and Gender-Based Violence.

Emergency departments are a common access point for survivors of sexual and gender-based violence (SGBV), but very little is known about where survivors live and the neighborhoods they return to. The objectives of this study were to describe the patient population that present for a sexual or partner-based assault and explore the geographic distribution of cases across the Ottawa-Gatineau area. Data for this study were extracted from the Sexual Assault and Partner Abuse Care Program (SAPACP) case registry (January 1 to December 31, 2015) at The Ottawa Hospital. Spatial analyses were conducted using six-digit postal codes converted into Canadian Census Tract units to identify geographic areas with concentrated cases of SGBV. Concentrated areas were defined as Census Tracts with seven or more SGBV cases within a single calendar year. In 2015, there were 406 patients seen at the SAPACP and 348 had valid postal codes and were included in the analyses. More than 90% of patients were female and 152 (43.68%) were below 24 years of age. More than 70% knew their assailant and the most common locations of the assault were at the survivors' home (31.03%), assailants' home (27.01%), or outdoors (10.92%). Eight concentrated areas were identified including three in the downtown entertainment district, three lower income areas, one high-income neighborhood, and one suburb more than 20 km from downtown. The findings from this study describe the typical clinical presentation of sexual and domestic assault survivors and also challenge geographic stereotypes of where survivors live and what areas of the city are most affected by SGBV. Using residential information provides a survivor-centric approach that highlights the widespread nature of SGBV and supports the need for population-based approaches to improve care for survivors.

HIV nonoccupational postexposure prophylaxis for sexual assault cases: a 3-year investigation.

OBJECTIVE: Nonoccupational postexposure prophylaxis (nPEP) programs offer antiretroviral therapy to prevent HIV following at-risk exposures like sexual assault. We investigated the levels of elective nPEP uptake among sexual assault cases presenting for emergency medical care. DESIGN: Retrospective analysis. METHODS: The analysis included over 3 years (1 January 2015 to 30 September 2018) of clinic information from the Sexual Assault and Partner Abuse Care Program (SAPACP) at The Ottawa Hospital, the regional emergency department care point following sexual assault. Descriptive analyses assessed the number of cases eligible for nPEP and those who started nPEP. Bivariable/multivariable logistic regression modelling assessed factors most strongly associated with starting nPEP using odds ratios (OR), adjusted OR (AOR), and 95% confidence intervals (CI). RESULTS: The SAPACP saw 1712 patients; 1032 were sexual assault cases, 494 were eligible for nPEP, and 307/494 (62%) eligible patients started nPEP. The median age was 23 years (IQR: 20-31), with 446 (90%) cases being female. There were 86 (17%) cases who arrived by ambulance, and 279 (56%) assaults involving a known assailant. Reduced odds of starting nPEP were observed among female cases (AOR: 0.44, 95% CI: 0.21-0.93), those who arrived by ambulance (AOR: 0.56, 95% CI: 0.35-0.91), and those with a known assailant (AOR: 0.56, 95% CI: 0.36-0.78). CONCLUSION: We found that 62% of eligible sexual assault cases started nPEP. Key groups most likely to decline nPEP included female cases, those who arrived by ambulance, and those with known assailants. Providers can use these findings to provide recommendations to sexual assault survivors most likely to decline nPEP, yet still in need of care.

Racial differences in contribution of prepregnancy obesity and excessive gestational weight gain to large-for-gestational-age neonates.

OBJECTIVES: To examine the racial differences in the population attributable fraction (PAF) of prepregnancy obesity and excessive gestational weight gain to large-for-gestational-age (LGA) neonates. METHODS: We conducted a population-based retrospective cohort study among all women who had prenatal screening and had a singleton live birth in a hospital (1 April 2016-31 March 2017) using data from Ontario birth registry in Canada. We used multivariable log-binomial regression models to estimate the PAF and 95% confidence interval (CI) of LGA neonates due to prepregnancy obesity and excessive gestational weight gain. All models were stratified by race (White, Asian, and Black). RESULTS: Of the 74,402 eligible women, the prevalence of prepregnancy obesity, excessive gestational weight gain, and LGA neonate was 21.1%, 60.0%, and 11.3%, respectively, for Whites; 9.3%, 45.9%, and 5.4%, respectively, for Asians; and 28.6%, 52.4%, and 7.9%, respectively, for Blacks. The association of prepregnancy obesity was greater than that of excessive gestational weight gain on LGA for all racial groups. Excessive gestational weight gain contributed more than prepregnancy obesity in Whites (PAF 32.9%, 95% CI [30.3-35.5%] and 16.6%, 95% CI [15.3-17.9%], respectively, for excessive gestational weight gain and prepregnancy obesity) and in Asians (PAF 32.1%, 95% CI [27.2-36.7%] and 11.8%, 95% CI [9.5-14.1%], respectively, for excessive gestational weight gain and prepregnancy obesity). Prepregnancy obesity (PAF 22.8%, 95% CI [17.1-28.1%]) and excessive gestational weight gain (PAF 20.1%, 95% CI [4.7-33.0%]) contributed to LGA neonates almost the same in Blacks. CONCLUSIONS: Excessive gestational weight gain contributed more to LGA neonates than prepregnancy obesity in Whites and Asians, while there was no difference between excessive gestational weight gain and prepregnancy obesity in their contributions to the LGA neonates in Blacks. The differences are mostly driven by the differential prevalence of the two risk factors across racial groups.

A 15-Year Population-Based Investigation of Sexual Assault Cases Across the Province of Ontario, Canada, 2002-2016.

Objectives. To estimate the population-level frequencies and standardized rates of sexual assault cases in the province of Ontario, Canada.Methods. We conducted a 15-year retrospective analysis (2002-2016) of sexual assault cases by linking 5 provincial administrative health databases. We defined sexual assault by an algorithm of 23 International Classification of Diseases, 10th Revision, and physician billing codes. We calculated age- and sex-stratified standardized rates per 100 000 census population, and we used age- and sex-stratified Poisson regressions to determine annual rate ratios.Results. Between 2002 and 2016, there were 52 780 incident cases of sexual assault in Ontario at a rate of 27.38 per 100 000 population. The highest rates were found among females aged 15 to 19 years (187 per 100 000) and 20 to 24 years (127 per 100 000). Among males, the highest rates were observed among children aged 0 to 4 years (41 per 100 000) and 5 to 9 years (29 per 10 000). Among males and females, the annual rate ratio increased among those aged 15 years and older and decreased among those aged 14 years and younger.Conclusions. Sexual assault was documented across all age groups and sexes, from children to elders, with high standardized rates among adolescents and children.