Cumulative effect of evidence-based practices on outcomes of preterm infants born at <29 weeks' gestational age.

BACKGROUND: Extremely preterm infants born at <29 weeks' gestational age are at high risk of death or severe neurological injury. Several individual evidence-based practices have been associated with neuroprotection. OBJECTIVE: The objective of the study was to investigate the cumulative effect of 4 evidence-based practices and their association with death and/or severe neurological injury among infants born at <29 weeks' gestational age. STUDY DESIGN: Observational study of infants born at 230-286 weeks gestational age admitted to neonatal intensive care units participating in the Canadian Neonatal Network from 2015 through 2017. We evaluated 4 practices: antenatal corticosteroids, antenatal MgSO4 for neuroprotection, deferred cord clamping ≥30 seconds, and normothermia on admission. The effect of exposure to 1, 2, 3, and all 4 evidence-based practices compared with none on death and/or severe neurological injury was assessed using multivariable logistic regression models adjusted for patient characteristics. RESULTS: Rate of death and/or severe neurological injury was 20% (873 of 4297) and varied based on exposure to evidence-based practices: none, 34% (54 of 157); 1, 27% (171 of 626); 2, 20% (295 of 1448); 3, 18% (263 of 1448); and all 4, 14% (90 of 618). Significantly lower odds of death and/or severe neurological injury were observed with exposure to antenatal corticosteroids (adjusted odds ratio, 0.52, 95% confidence interval, 0.40-0.69) and deferred cord clamping (adjusted odds ratio, 0.81, 95% confidence interval, 0.68-0.96) but not MgSO4 (adjusted odds ratio, 0.88, 95% confidence interval, 0.72-1.08) or normothermia (adjusted odds ratio, 0.96, 95% confidence interval, 0.79-1.16). Infants exposed to ≥2 evidence-based practices had significantly lower odds of death and/or severe neurological injury than those exposed to no evidence-based practices (adjusted odds ratio, 0.61, 95% confidence interval, 0.43-0.88). CONCLUSION: Among infants born at <29 weeks' gestational age, exposure to at least 2 of the evidence-based practices assessed was associated with decreased odds of death and/or severe neurological injury.

Outcomes of Selective Reduction of DCDA Twins Complicated by PV-PROM Compared with Expectant Management: A Case Series and Review of the Literature.

OBJECTIVE: To report the outcomes of selective reduction (SR) in dichorionic twins complicated by pre-viable, premature rupture of membranes (PV-PROM). METHODS: Retrospective case series. Ultrasound database was searched for cases of dichorionic twin pregnancy with PV-PROM, either managed conservatively or with SR. Chart reviews were done for these cases. Simple descriptive statistics were used where appropriate. RESULTS: Twenty-two cases of expectantly managed dichorionic twins complicated by PV-PROM with delivery information were available for analysis. Mean GA at PV-PROM was 20.6 weeks, mean GA of delivery was 27.6 weeks, and the mean latency was 39.6 days. There were five cases of SR following PV-PROM in dichorionic twin pregnancies. Mean GA of PV-PROM was 17.0 weeks. Average time from PV-PROM to procedure was 2.5 weeks. Mean GA of delivery of the surviving fetus was 32.6 weeks (P = 0.20) with mean latency of 108 days (P = 0.06). Twelve additional cases have been published and are summarized along with our five cases. CONCLUSION: There was a trend towards an increase in latency interval between cases of PV-PROM managed by SR and expectant management in our institution. When combined with the existing literature data, there may be an improvement in latency.

Correction to: The Cedar Project: Using Indigenous-specific determinants of health to predict substance use among young pregnant-involved Indigenous women in Canada.

After publication of the original article (1) it was noted that the title of this manuscript was incorrect. The title presently reads "The cedar project: using indigenous-specific determinants of health to predict substance use among young pregnant-involved aboriginal women" but should read "The Cedar Project: Using Indigenous-specific determinants of health to predict substance use among young pregnant-involved Indigenous women in Canada".

The Cedar Project: Using Indigenous-specific determinants of health to predict substance use among young pregnant-involved Indigenous women in Canada.

BACKGROUND: Indigenous women in Canada have been hyper-visible in research, policy and intervention related to substance use during pregnancy; however, little is known about how the social determinants of health and substance use prior to, during, and after pregnancy intersect. The objectives of this study were to describe the social contexts of pregnant-involved young Indigenous women who use substances and to explore if an Indigenous-Specific Determinants of Health Model can predict substance use among this population. METHODS: Using descriptive statistics and hierarchical logistic regression guided by mediation analysis, the social contexts of pregnant-involved young Indigenous women who use illicit drugs' lives were explored and the Integrated Life Course and Social Determinants Model of Aboriginal Health's ability to predict heavy versus light substance use in this group was tested (N = 291). RESULTS: Important distal determinants of substance use were identified including residential school histories, as well as protective factors, such as sex abuse reporting and empirical evidence for including Indigenous-specific determinants of health as important considerations in understanding young Indigenous women's experiences with pregnancy and substance use was provided. CONCLUSIONS: This analysis provided important insight into the social contexts of women who have experiences with pregnancy as well as drug and/or alcohol use and highlighted the need to include Indigenous-specific determinants of health when examining young Indigenous women's social, political and historical contexts in relation to their experiences with pregnancy and substance use.

Risks and consequences of puerperal uterine inversion in the United States, 2004 through 2013.

BACKGROUND: Puerperal uterine inversion is a rare, potentially life-threatening obstetrical emergency. The current literature consists of small case series and a single nationwide study from Europe with only 15 cases. OBJECTIVE: We aimed to define the incidence, temporal trends, and outcomes in women with uterine inversion using a nationally representative US cohort. STUDY DESIGN: We used the Nationwide Inpatient Sample, a 20% sample of US hospital admissions, to identify all deliveries from 2004 through 2013. International Classification of Diseases, Ninth Revision diagnosis codes were used to identify cases of uterine inversion and associated adverse outcomes (maternal death, blood transfusion, maternal shock, need for surgical correction, and length of hospital stay). The incidence of uterine inversion overall and for each year of the study period was calculated with 95% confidence intervals. The case fatality and incidence of other adverse outcomes among women with a uterine inversion were also estimated. RESULTS: Among 8,294,279 deliveries in 2004 through 2013, there were 2427 cases of puerperal uterine inversion, corresponding to an incidence of 2.9 per 10,000 deliveries (95% confidence interval, 2.8-3.0). There was 1 maternal death in our cohort (4.1 per 10,000 events). No change in the incidence of uterine inversion over the study period was detected. Among women with a uterine inversion, 37.7% (95% confidence interval, 35.8-39.6%) had an associated postpartum hemorrhage, 22.4% (95% confidence interval, 20.7-24.0%) received a blood transfusion, and 6.0% (95% confidence interval, 5.1-7.0%) required surgical management. Only 2.8% (95% confidence interval, 2.1-3.5%) underwent a hysterectomy. The median length of hospital stay was 3 days. CONCLUSION: This study provides the largest population-based results on puerperal uterine inversion to date and highlights the high likelihood of adverse maternal outcomes associated with the condition. The results inform the optimization of clinical management, by preparing for possible postpartum hemorrhage, need for blood products, and surgical management in the rare event of uterine inversion.

Maternal morbidity and perinatal outcomes among women in rural versus urban areas.

BACKGROUND: Most studies examining geographic barriers to maternity care in industrialized countries have focused solely on fetal and neonatal outcomes. We examined the association between rural residence and severe maternal morbidity, in addition to perinatal mortality and morbidity. METHODS: We conducted a retrospective population-based cohort study of all women who gave birth in British Columbia, Canada, between Jan. 1, 2005, and Dec. 31, 2010. We compared maternal mortality and severe morbidity (e.g., eclampsia) and adverse perinatal outcomes (e.g., perinatal death) between women residing in areas with moderate to no metropolitan influence (rural) and those living in metropolitan areas or areas with a strong metropolitan influence (urban). We used logistic regression analysis to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: We found a significant association between death or severe maternal morbidity and rural residence (adjusted OR 1.15, 95% CI 1.03-1.28). In particular, women in rural areas had significantly higher rates of eclampsia (adjusted OR 2.70, 95% CI 1.79-4.08), obstetric embolism (adjusted OR 2.16, 95% CI 1.14-4.07) and uterine rupture or dehiscence (adjusted OR 1.96, 95% CI 1.42-2.72) than women in urban areas. Perinatal mortality did not differ significantly between the study groups. Infants in rural areas were more likely than those in urban areas to have a severe neonatal morbidity (adjusted OR 1.14, 95% CI 1.02-1.29), to be born preterm (adjusted OR 1.06, 95% CI 1.01-1.11), to have an Apgar score of less than 7 at 5 minutes (adjusted OR 1.24, 95% CI 1.13-1.31) and to be large for gestational age (adjusted OR 1.14, 95% CI 1.10-1.19). They were less likely to be small for gestational age (adjusted OR 0.90, 95% CI 0.85-0.95) and to be admitted to an neonatal intensive care unit (NICU) (adjusted OR 0.36, 95% CI 0.33-0.38) compared with infants in urban areas. INTERPRETATION: Compared with women in urban areas, those in rural areas had higher rates of severe maternal morbidity and severe neonatal morbidity, and a lower rate of NICU admission. Maternity care providers in rural regions need to be aware of potentially life-threatening maternal and perinatal complications requiring advanced obstetric and neonatal care.

Differences in obstetric care among nulliparous First Nations and non-First Nations women in British Columbia, Canada.

BACKGROUND: Canada's Aboriginal population faces significantly higher rates of stillbirth and neonatal and postnatal death than those seen in the general population. The objective of this study was to compare indicators of obstetric care quality and use of obstetric interventions between First Nations and non-First Nations mothers in British Columbia, Canada. METHODS: We linked obstetrical medical records with the First Nations Client File for all nulliparous women who delivered single infants in British Columbia from 1999 to 2011. Using logistic regression models, we examined differences in the proportion of women who received services aligned with best practice guidelines, as well as the overall use of obstetric interventions among First Nations mothers compared with the general population, controlling for geographic barriers (distance to hospital) and other relevant confounders. RESULTS: During the study period, 215,993 single births occurred in nulliparous women in British Columbia, 9152 of which were to members of our First Nations cohort. First Nations mothers were less likely to have early ultrasonography (adjusted risk difference = 10.2 fewer women per 100 deliveries [95% confidence interval {CI} -11.3 to -9.3]), to have at least 4 antenatal care visits (3.6 fewer women per 100 deliveries [95% CI -4.6 to -2.6]), and to undergo labour induction after prolonged (> 24 hours) prelabour rupture of membranes (-5.9 [95% CI -11.8 to 0.1]) or at post-dates gestation (-10.6 [95% CI -13.8 to -7.5]). Obstetric interventions including epidural, labour induction, instrumental delivery and cesarean delivery were used less often in First Nations mothers. INTERPRETATION: We identified differences in the obstetric care received by First Nations mothers compared with the general population. Such differences warrant further investigation, given increases in perinatal mortality that are consistently shown and that may be a downstream consequence of differences in care.

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.

Rationalizing definitions and procedures for optimizing clinical care and public health in fetal death and stillbirth.

Despite the recent focus on stillbirth, there remains a profound need to address problems associated with the definitions and procedures related to fetal death and stillbirth. The current definition of fetal death, first proposed in 1950, needs to be updated to distinguish between the timing of fetal death (which has etiologic and prognostic significance) and the timing of stillbirth (ie, the delivery of the dead fetus). Stillbirth registration procedures, modeled after live birth registration and not death registration, also need to be modernized because they can be an unnecessary burden on some grieving families. The problems associated with fetal death definitions and stillbirth-associated procedures are highlighted by selective fetal reduction in multifetal pregnancy; in many countries, the fetus reduced at 10-13 weeks of gestation and delivered at term gestation requires stillbirth registration and a burial permit even if fetal remains cannot be identified. An international consensus is needed to standardize the definition of reportable fetal deaths; ideally this should be based on the timing of fetal death and should address the status of pregnancy terminations. In this article, we list propositions for initiating an international dialogue that will rationalize fetal death definitions, registration criteria, and associated procedures, and thereby improve clinical care and public health.

Birth outcomes in newborns fathered by men with multiple sclerosis exposed to disease-modifying drugs.

OBJECTIVE: The aim of this study was to determine the incidence of births fathered by men with multiple sclerosis (MS) exposed to a disease-modifying drug (DMD) around the time of conception, and investigate the association between DMD exposure and birth outcomes in newborns of exposed and unexposed MS fathers. METHODS: Population-based databases in British Columbia (BC), Canada, (the BCMS database, Vital Statistics Birth Registry, Population Data BC Consolidation File/Census GeoData, BC PharmaNet and the BC Perinatal Database Registry) were linked in this retrospective cohort study (1996 to 2010). Multivariate models were used to examine the association between interferon-beta (IFNß) or glatiramer acetate (GA) exposure (within 64 days prior to or at conception; i.e., the duration of spermatogenesis) with birth weight and gestational age of newborns. RESULTS: Of 195 births fathered by men with relapsing-onset MS, 80 births (41%) were to fathers treated with a DMD before their child was born, with 53/195 (27%) exposed within 64 days prior to or at the time of conception. Of the 53 exposed births, 37 were to IFNß and 16 to GA. Mean birth weight of IFNß-exposed and GA-exposed newborns was similar to that of unexposed newborns (adjusted difference: -107 g for both, p>0.3). IFNß-exposed and GA-exposed newborns also had comparable mean gestational ages relative to unexposed newborns (adjusted difference: -0.5 and -0.3 weeks, respectively, p>0.2). CONCLUSIONS: About one in three would-be fathers with MS were exposed to IFNß or GA around the time of conception; there was no compelling evidence to suggest that exposure was associated with either lower birth weight or gestational age.

A review of safety-related pregnancy data surrounding the oral disease-modifying drugs for multiple sclerosis.

The recent approval of several oral disease-modifying drugs (DMDs) for multiple sclerosis (MS) brings promise of improved clinical effectiveness as well as greater drug compliance compared to the existing non-oral DMDs, and substantially increases patient choice and therapeutic options in the effective management of MS. However, for men and women with MS of childbearing age, concerns about the effect of oral DMDs on pregnancy and the fetus may arise. Some limited data from animal reproductive studies of oral DMDs suggest a potential increased risk of early pregnancy loss, impaired growth and birth defects. Although active surveillance mechanisms exist, there is limited data to inform clinical practice. Using existing information from published clinical trials and drug monographs, as well as recent conference proceedings, this review summarizes the mechanism of action (in relation to embryogenesis and pregnancy) and existing animal or human pregnancy-related data for approved (fingolimod, teriflunomide and dimethyl fumarate) and investigational (laquinimod and firategrast) oral DMDs for MS.

Obstetrical epidural and spinal anesthesia in multiple sclerosis.

To examine obstetrical epidural and spinal anesthesia use in women with multiple sclerosis (MS) and the relationship with MS clinical factors. This was a retrospective cohort study, linking clinical data from women with MS in the British Columbia (BC) MS database to obstetrical data (1998-2009) from the BC Perinatal Database Registry. We compared epidural use in 431 deliveries to women with MS and 2,959 deliveries from the general population, as well as spinal use in cesarean deliveries (128 to women with MS and 846 in the general population), considering parity and using multivariate models. We also examined the association between epidural or spinal anesthesia and MS clinical factors-disease duration and disability [Expanded Disability Status Scale (EDSS) score]. Of 431 deliveries to women with MS, 116 were exposed to epidural anesthesia and of 128 cesarean deliveries, 82 were exposed to spinal anesthesia. The use of epidural anesthesia was similar in nullipara (adjusted OR = 0.86, 95 % CI = 0.63-1.18, p = 0.36), but more likely in multipara with MS (adjusted OR = 1.75, 95 % CI = 1.20-2.54, p = 0.004). Spinal anesthesia use in cesarean deliveries was comparable between the MS and general population cohorts (adjusted OR = 0.84, 95 % CI = 0.55-1.31, p = 0.45). Women who delivered 5 to <10 years after MS onset were less likely to have an epidural (adjusted OR = 0.57, 95 % CI = 0.34-0.95, p = 0.03) vs. those delivering within 5 years. EDSS was not associated with use of either type of anesthesia (adjusted p > 0.1). Contrary to previous studies, epidural anesthesia use differed between women with MS and the general population and was influenced by parity and MS disease duration; these findings warrant further investigation.

Safety of disease-modifying drugs for multiple sclerosis in pregnancy: current challenges and future considerations for effective pharmacovigilance.

When contemplating a pregnancy, women treated for multiple sclerosis (MS) with a disease-modifying drug must decide to discontinue their medication before conception or risk exposing their unborn child to potential drug toxicity. Few studies exist as reference for patients and physicians, and of those available, the majority are less than ideal due to real-world constraints, ethical issues and methodological shortcomings. The authors provide a brief summary of existing animal and human data with current recommendations regarding the safety of IFN-ß, glatiramer acetate, natalizumab, mitoxantrone, fingolimod and teriflunomide during pregnancy and lactation in women with MS. We also assess the quality, strengths and limitations of the existing studies including challenges with study design. The investigation of outcomes such as spontaneous abortion and congenital anomalies are highlighted with potential methodological improvements for future studies on drug safety in pregnancy suggested. The authors explore the pharmacokinetics and pharmacodynamics of the MS disease-modifying drugs for their possible mechanistic role in fetal harm and discuss the potential role of clinical trials. Future pharmacovigilance studies should continue to pursue multicenter collaboration with an emphasis on appropriate study design.

Birth hospitalization in mothers with multiple sclerosis and their newborns.

OBJECTIVE: To compare the duration of birth hospitalization in mothers with multiple sclerosis (MS) and their newborns relative to the general population and to investigate the impact of MS-related clinical factors on the length of birth hospitalization stays. METHODS: Data from the British Columbia Perinatal Database Registry and the British Columbia MS database were linked in this retrospective cohort study. The duration of birth hospitalization in mothers with MS and their newborns (n = 432) were compared with a frequency-matched sample of the general population (n = 2,975) from 1998 to 2009. Clinical factors investigated included disease duration and disability, as measured by the Expanded Disability Status Scale. A multivariable model (generalized estimating equations) was used to analyze the association between MS and duration of birth hospitalization, adjusting for factors such as maternal age, diabetes, hypertension, and consecutive births to the same mother. Additional analyses included propensity score matching to further balance cohort characteristics. RESULTS: Compared with the general population, the duration of birth hospitalization was not statistically or clinically different for mothers with MS or their newborns (median differences = +1.5 and +2.1 hours, respectively; adjusted p > 0.4). Lengths of birth hospitalization were not significantly associated with disease duration (adjusted p > 0.7) or level of disability (adjusted p > 0.5). Findings remained virtually unchanged after propensity score matching. CONCLUSIONS: Birth hospitalization has been understudied in women with MS. Contrary to existing studies, we found that MS was not associated with a longer birth hospitalization. This study provides assurance to expectant mothers with MS, their families, and health care providers.

Neonatal and delivery outcomes in women with multiple sclerosis.

OBJECTIVE: To determine (1) whether the risk of adverse neonatal and delivery outcomes differs between mothers with and without multiple sclerosis (MS) and (2) whether risk is differentially associated with clinical factors of MS. METHODS: This retrospective cohort study analyzed data from the British Columbia (BC) MS Clinics' database and the BC Perinatal Database Registry. Comparisons were made between births to women with MS (n = 432) and to a frequency-matched sample of women without MS (n = 2,975) from 1998 to 2009. Outcomes included gestational age, birth weight, assisted vaginal delivery, and Caesarean section. Clinical factors examined included age at MS onset, disease duration, and disability. Multivariate regression models adjusting for confounding factors were built for each outcome. RESULTS: Babies born to MS mothers did not have a significantly different mean gestational age or birth weight compared to babies born to mothers without MS. MS was not significantly associated with assisted vaginal delivery (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.50-1.16; p = 0.20) or Caesarean section (OR, 0.94; 95% CI, 0.69-1.28; p = 0.69). There was a slightly elevated risk of adverse delivery outcomes among MS mothers with greater levels of disability, although findings were not statistically significant. Disease duration and age at MS onset were not significantly associated with adverse outcomes. INTERPRETATION: This study provides reassurance to MS patients that maternal MS is generally not associated with adverse neonatal and delivery outcomes. However, the suggestion of an increased risk with greater disability warrants further investigation; these women may require closer monitoring during pregnancy.

Birth outcomes among older mothers in rural versus urban areas: a residence-based approach.

PURPOSE: We examined the association between rural residence and birth outcomes in older mothers, the effect of parity on this association, and the trend in adverse birth outcomes in relation to the distance to the nearest hospital with cesarean-section capacity. METHODS: A population-based retrospective cohort study, including all singleton births to 35+ year-old women in British Columbia (Canada), 1999-2003. We compared birth outcomes in rural versus urban areas, and between 3 distance categories to a hospital (<50, 50-150, >150 km). Outcomes included labor induction, cesarean section, stillbirth, perinatal death, preterm birth (<37 weeks), small-for-gestational-age, large-for-gestational-age, and neonatal intensive care unit admission. We used multivariate regression to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs). FINDINGS: Among the 29,698 subjects, 11.5% lived in rural areas; 5% lived within 50-150 km; and 1.1% lived >150 km from a hospital. Rural women were at lower risk of primary and repeat cesarean section (OR = 0.9, CI: 0.9-1.0; OR = 0.7, CI: 0.6-0.9) and small-for-gestational-age (OR = 0.8, CI: 0.7-0.9) births; they were at increased risk for perinatal death (OR = 1.5, CI: 1.1-2.1) and large-for-gestational-age (OR = 1.1, CI: 1.1-1.2) births. The association was stronger among multiparous versus primiparous women. No differences in emergency cesarean section, preterm birth, or neonatal intensive care admission were found, regardless of parity. Perinatal mortality increased with distance from hospital; OR = 1.5 (CI: 1.1-2.1) per distance category. CONCLUSIONS: Older women in rural versus urban areas had a lower rate of cesarean section and increased risk of perinatal death. The risk of perinatal death increased with the distance to hospital. Further studies need to evaluate the contribution of underlying perinatal risks, access to care, and decision making regarding referral and transport.

The effect of maternal age on adverse birth outcomes: does parity matter?

OBJECTIVES: To examine the effect of parity on the association between older maternal age and adverse birth outcomes, specifically stillbirth, neonatal death, preterm birth, small for gestational age, and neonatal intensive care unit admission. METHODS: We conducted a retrospective cohort study of singleton births in British Columbia between 1999 and 2004. In the cohort, 69 023 women were aged 20 to 29, 25 058 were aged 35 to 39, and 4816 were aged 40 and over. Perinatal risk factors, obstetric history, and birth outcomes were abstracted from the British Columbia Perinatal Database Registry. Logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals for adverse outcomes in the two older age groups compared with the young control subjects. RESULTS: Compared with younger control subjects, women aged 35 to 39 years had an aOR of stillbirth of 1.5 (95% CI 1.2 to 1.9) and women aged >or= 40 years also had an aOR of 1.5 (95% CI 1.0 to 2.4). The aOR for NICU admission was 1.2 (95% CI 1.0 to 1.3) in women aged 35 to 39 years and 1.4 (95% CI 1.1 to 17) in women aged >or= 40 years compared with younger control subjects. The risk of preterm birth and SGA differed by parity. The aOR for preterm birth compared with younger primiparas was 1.5 (95% CI 1.4 to 1.7) for women aged 35 to 39 years and 1.6 (95% CI 1.3 to 2.0) for women aged >or= 40 years. In multiparas the aOR for preterm birth was 1.1 (95% CI 1.1 to 1.2) in women aged 35 to 39 and 1.3 (95% CI 1.1 to 1.5) in women >or= 40 years. The aOR for SGA in primiparas was 1.2 (95% CI 1.1 to 1.4) for women aged 35 to 39 and 1.4 (95% CI 1.1 to 1.7) for women aged >or= 40 years. The risk of neonatal death was not significantly different between groups. CONCLUSION: Older women were at elevated risk of stillbirth, preterm birth, and NICU admission regardless of parity. Parity modified the effect of maternal age on preterm birth and SGA. Older primiparas were at elevated risk for SGA, but no association between age and SGA was found in multiparas. Older primiparas were at higher risk of preterm birth than older multiparas compared with younger women.

Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants.

OBJECTIVE: To determine the risks and benefits of an elective Caesarean section (CS) at term in healthy nulliparous women. METHODS: We conducted a population-based cohort study of deliveries between 1994 and 2002. Using bivariate and multivariable techniques, we compared maternal and neonatal outcomes in healthy nulliparous women who had undergone elective pre-labour CS (using breech presentation as a surrogate) with those in women who had undergone spontaneous labour with anticipated vaginal delivery (SL) at full term. RESULTS: There were 1046 deliveries in the pre-labour CS group and 38 021 in the SL group. Life-threatening maternal morbidity was similar in each group. Life-threatening neonatal morbidity was decreased in the CS group (RR 0.34; 99% CI 0.12 to 0.97). Subgroup analysis of the SL group by mode of delivery demonstrated the increased neonatal risk was associated with operative vaginal delivery and intrapartum CS but not spontaneous vaginal delivery. CONCLUSION: An elective pre-labour Caesarean section in a nulliparous woman at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery. However, the 63% of women with spontaneous labour who achieved a spontaneous vaginal delivery would not have benefited from delivery by Caesarean section. Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum Caesarean section, as this may assist maternity caregivers in decision-making about childbirth. Further research is also needed to determine if these findings can be confirmed in a prospective study.

Socioeconomic status and perinatal outcomes in a setting with universal access to essential health care services.

BACKGROUND: The health care system in Canada provides essential health services to all women irrespective of socioeconomic status. Our objective was to determine whether perinatal and infant outcomes varied by family income and other socioeconomic factors in this setting. METHODS: We included all 92,914 women who delivered in Nova Scotia between 1988 and 1995 following a singleton pregnancy. Family income was obtained for 76,440 of these women through a confidential link to income tax records and was divided into 5 groups. Outcomes studied included pregnancy complications, preterm birth, small-for-gestational-age live birth, perinatal death, serious neonatal morbidity, postneonatal death and infant death. Logistic regression models were used to adjust for potential confounders. RESULTS: Compared with women in the highest family income group, those in the lowest income group had significantly higher rates of gestational diabetes (crude rate ratio [RR] 1.44, 95% confidence interval [CI] 1.21-1.73), preterm birth (crude RR 1.20, 95% CI 1.06-1.35), small-for-gestational-age live birth (crude RR 1.81, 95% CI 1.66-1.97) and postneonatal death (crude RR 5.54, 95% CI 2.21-13.9). The opposite was true for rates of perinatal death (crude RR 0.74, 95% CI 0.56-0.96), and there was no significant difference between the 2 groups in the composite of perinatal death or serious neonatal morbidity (crude RR 1.01, 95% CI 0.82-1.24). Adjustment for behavioural and lifestyle factors accentuated or attenuated socioeconomic differences. INTERPRETATION: Lower family income is associated with increased rates of gestational diabetes, small-for-gestational-age live birth and postneonatal death despite health care services being widely available at no out-of-pocket expense.

Pregnancy with uterine vascular malformations associated with hemorrhagic hereditary telangiectasia: a case report.

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant condition. It is rarely seen in pregnancy and even more rarely has uterine manifestations. CASE: A 29-year-old primigravid woman with HHT was noted to have vascular manifestations of her disease in the lower uterus, distal rectum, pelvis, and bladder before pregnancy. Prior to delivery, a case conference was held, involving representatives of the departments of vascular surgery, hematology, radiology, anaesthesiology, maternal-fetal medicine, neonatology, and laboratory medicine, and other appropriate health professionals. A successful elective Caesarean section was performed at term, with a good outcome for both mother and child. CONCLUSION: regnancies in women with HHT and associated uterine vascular manifestations have been rarely reported, and published information is minimal. We present a case of a successful operative delivery following careful multidisciplinary antepartum care.