Neonatal Adverse Outcomes among Hospital Livebirths in Canada: A National Retrospective Study.

INTRODUCTION: In Canada, newborn morbidity far surpasses mortality. The neonatal adverse outcome indicator (NAOI) summarizes neonatal morbidity, but Canadian trend data are lacking. METHODS: This Canada-wide retrospective cross-sectional study included hospital livebirths between 24 and 42 weeks' gestation, from 2013 to 2022. Data were obtained from the Canadian Institute of Health Information's Discharge Abstract Database, excluding Quebec. The NAOI included 15 newborn complications (e.g., birth trauma, intraventricular hemorrhage, or respiratory failure) and seven interventions (e.g., resuscitation by intubation and/or chest compressions), adapted from Australia's NAOI. Rates of NAOI were calculated by gestational age. Unadjusted rate ratios (RR) and 95% confidence interval (CI) were calculated for neonatal mortality, neonatal intensive care unit (NICU) admission, and extended hospital stay, each in relation to the number of NAOI components present (0, 1, 2, 3, 4, or ≥5). RESULTS: Among 2,821,671 newborns, the NAOI rate was 7.6%. NAOI increased from 7.3% in 2013 to 8.0% in 2022 (p < 0.01). NAOI prevalence was highest in the most preterm infants. Compared to no NAOI, RRs (95% CI) for mortality were 8.5 (7.6-9.5) with 1, 118.1 (108.4-128.4) with 3, and 395.3 (367.2-425.0) with ≥5 NAOI components. Respective RRs for NICU admission were 6.7 (6.6-6.7), 11.2 (10.9-11.3), and 11.9 (11.6-12.2), and RR for extended hospital stay were 6.6 (6.4-6.7), 12.2 (11.7-12.7), and 26.4 (25.2-27.5). International comparison suggested that Canada had a higher prevalence of NAOI. CONCLUSION: The Canadian NAOI captures neonatal morbidity using hospitalization data and is associated with neonatal mortality, NICU admission, and extended hospital stay. Newborn morbidity may be on the rise in recent years.

Trends in rate of hypertensive disorders of pregnancy and associated morbidities in Canada: a population-based study (2012-2021).

BACKGROUND: Hypertensive disorders of pregnancy (HDP) are a leading cause of severe maternal morbidity (SMM). We sought to explore trends in HDP and related morbidity outcomes in Canada. METHODS: In this retrospective population-based study, we used hospital discharge data from Canada, excluding Quebec, to identify females who had an HDP diagnosis during a birth admission between 2012 and 2021. We analyzed temporal and geographical trends in HDP, as well as temporal trends in adverse outcomes associated with HDP. RESULTS: Among 2 804 473 hospital admissions for birth between 2012 and 2021, the rate of any HDP increased from 6.1% to 8.5%, including pre-existing hypertension (0.6% to 0.9%), gestational hypertension (3.9% to 5.1%), and preeclampsia (1.6% to 2.6%). For 2017-2021 combined, relative to Ontario (6.9%), HDP were significantly more prevalent in nearly all other Canadian regions. For example, in Newfoundland and Labrador, the rate was 10.7% (unadjusted rate ratio 1.56, 95% confidence interval 1.49-1.63). Among females with any HDP, rates of cesarean delivery rose from 42.0% in 2012 to 44.3% in 2021, as did acute renal failure (0.4% to 0.6%), while rates of early preterm delivery, intrauterine fetal death, maternal hospital length of stay (≥ 7 d), admission to the maternal intensive care unit, severe hemorrhage, and SMM trended downward. INTERPRETATION: The rate of HDP has risen across Canada, with a concomitant decline in some HDP-associated morbidities. Ongoing surveillance of HDP is needed to assess the factors associated with temporal trends, including the effectiveness of evolving HDP prevention and management efforts.

Diabetes mellitus in pregnancy across Canada.

BACKGROUND: Contemporary estimates of diabetes mellitus (DM) rates in pregnancy are lacking in Canada. Accordingly, this study examined trends in the rates of type 1 (T1DM), type 2 (T2DM) and gestational (GDM) DM in Canada over a 15-year period, and selected adverse pregnancy outcomes. METHODS: This study used repeated cross-sectional data from the Canadian Institute of Health Information (CIHI) hospitalization discharge abstract database (DAD). Maternal delivery records were linked to their respective birth records from 2006 to 2019. The prevalence of T1DM, T2DM and GDM were calculated, including relative changes over time, assessed by a Cochrane-Armitage test. Also assessed were differences between provinces and territories in the prevalence of DM. RESULTS: Over the 15-year study period, comprising 4,320,778 hospital deliveries in Canada, there was a statistically significant increase in the prevalence of GDM and T1DM and T2DM. Compared to pregnancies without DM, all pregnancies with any form of DM had higher rates of hypertension and Caesarian delivery, and also adverse infant outcomes, including major congenital anomalies, preterm birth and large-for-gestational age birthweight. CONCLUSION: Among 4.3 million pregnancies in Canada, there has been a rise in the prevalence of DM. T2DM and GDM are expected to increase further as more overweight women conceive in Canada.

Validation of Ultrasound Dating Protocols Using Data From Twins Conceived Through In Vitro Fertilization in Nova Scotia: A Retrospective Cohort Study.

OBJECTIVES: Clinical practice guidelines recommend determining gestational age (GA) for twin pregnancies using the fetal crown rump length (CRL) of the larger fetus. This study investigated whether the CRL of the larger or smaller fetus at 11-14 weeks best predicted in vitro fertilization (IVF) assigned GA. METHODS: A retrospective cohort study of twin pregnancies conceived by IVF ± intracytoplasmic sperm injection, 2004-2022, generated GA estimations for each co-twin CRL at the 11-14 week ultrasound, to determine which fetus (smaller or larger) more consistently predicted IVF-assigned GA. Monoamniotic twins and twins with known structural or vascular abnormalities were excluded. Paired t tests evaluated the ability of CRL to predict GA, and logistic regression evaluated the predictive ability of each of the co-twin groups with increasing size differences. Statistical significance was set at P < 0.05. RESULTS: Viewpoint 6 identified 359 eligible twin pairs. CRL was closest with the smaller fetus (0.38 days); CRL for both the smaller (95% CI 0.16-0.61) and the larger (2.25 days, 95% CI 2.04-2.46) fetus showed deviation from IVF-assigned GA. As the absolute difference between the small and large fetus increased, the ultrasound-estimated GA of the smaller fetus was still consistently closer to IVF-assigned GA. CONCLUSIONS: In this selected population of twins with known GA, the CRL of the smaller fetus more accurately predicted IVF-assigned GA even with increasing differences in fetal size. These findings provide important information for appropriately dating pregnancies to facilitate adherence to national guidelines to monitor for pregnancy complications, and plan frequency and type of fetal surveillance, as well as timing of delivery.

Guideline No. 421: Point of Care Ultrasound in Obstetrics and Gynaecology.

OBJECTIVE: To provide an opinion regarding the usefulness of point of care ultrasound in obstetrics and gynaecology. TARGET POPULATION: Women with pregnancy-related complications or issues who could benefit from an urgent bedside sonographic evaluation. OPTIONS: Point of care ultrasound is a readily accessible option, requiring few resources. BENEFITS, HARMS, AND COSTS: This low-cost imaging option can expedite appropriate patient management, enhance provider confidence, and allay the patient's anxiety in a timely fashion. However, there is potential for error in imaging or interpretation, resulting in incorrect and potentially harmful patient management. EVIDENCE: MEDLINE, PubMed, Embase, and the Cochrane Library weres earched from 2009 to 2019. Medical Subject Headings (MeSH) and keywords were related to pregnancy, PoCUS, point of care ultrasound, and bedside ultrasound. This document represents an abstraction of the evidence rather than a methodological review. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Providers of urgent care for pregnant women (obstetricians and gynaecologists, family physicians, emergency room physicians, midwives, nurse practitioners, nurses). SUMMARY STATEMENT (GRADE RATINGS IN PARENTHESES): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Database Autopsy: An Efficient and Effective Confidential Enquiry into Maternal Deaths in Canada.

BACKGROUND: Maternal death surveillance in Canada relies on hospitalization data, which lacks information on the underlying cause of death. We developed a method for identifying underlying causes of maternal death, and quantified the frequency of maternal death by cause. METHODS: We used data from the Discharge Abstract Database for fiscal years 2013 to 2017 to identify women who died in Canadian hospitals (excluding Quebec) while pregnant or within 1 year of the end of pregnancy. A sequential narrative based on hospital admission(s) during and after pregnancy was constituted and reviewed to assign the underlying cause of death (based on the World Health Organization's framework). Maternal deaths (i.e., while pregnant or within 42 days after the end of pregnancy) and late maternal deaths (i.e., more than 42 days to a year after the end of pregnancy) were examined separately. RESULTS: We identified 85 maternal deaths. Direct obstetric causes included 8 deaths (9%) related to complications of spontaneous or induced abortion; 9 (11%), to hypertensive disorders of pregnancy; 15 (18%), to obstetric hemorrhage; 11 (13%), to pregnancy-related infection; 16 (19%), to other obstetric complications; and <5 (<6%), to complications of management. There were 21 (25%) maternal deaths with indirect obstetric causes, and <5 (<6%) with undetermined causes. Of 120 late maternal deaths, 16 (13%) had direct obstetric causes, among them, 9 deaths by suicide (56%). One hundred late maternal deaths (83%) had indirect obstetric causes; and <5 (<4%) had undetermined causes. CONCLUSIONS: The majority of maternal deaths in Canada have direct obstetric causes, whereas most late maternal deaths have indirect obstetric causes. Suicide is an important direct cause of late maternal death.

No 375 - Directive clinique sur l'utilisation de l'échographie au premier trimestre.

OBJECTIF: Révision des indications cliniques de l'échographie du premier trimestre. RéSULTATS: L'échographie au premier trimestre offre des avantages cliniques démontrés. DONNéES PROBANTES: Les données probantes ont été révisées au moyen de recherche dans Medline et selon la bibliographie des articles pertinents. VALEURS: Le contenu et les recommandations ont été évalués par les auteurs principaux et le Comité d'imagerie diagnostique de la Société des obstétriciens et gynécologues du Canada. Le niveau d'évidence a été défini en fonction des critères du Groupe d'étude canadien sur les soins de santé préventifs. RECOMMANDATIONS.

No. 375-Clinical Practice Guideline on the Use of First Trimester Ultrasound.

OBJECTIVE: This guideline reviews the clinical indications for first trimester ultrasound. OUTCOME: Proven clinical benefit has been reported from first trimester ultrasound. EVIDENCE: A Medline search and bibliography reviews in relevant literature provided the evidence. VALUES: Content and recommendations were reviewed by the principal authors and the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada. Levels of evidence were judged as outlined by the Canadian Task Force on Preventive Health Care.

Predictors for surgical intervention and surgical outcomes in neonates with cystic fibrosis.

BACKGROUND/PURPOSE: To identify prenatal and perinatal predictors of surgery and describe surgical findings/outcomes of neonates with Meconium Ileus (MI) secondary to Cystic Fibrosis (CF). METHODS: Potential risk factors (prenatal bowel echogenicity, CF genotype, birthweight, prematurity and sex) for MI and surgery were examined in a retrospective cohort of neonates with CF presenting to a tertiary center between 1997 and 2015. Following univariable analysis, predictors of MI and surgery were determined using multivariable logistic regression. For surgical patients, detailed operative findings and outcomes were examined. RESULTS: MI was diagnosed in 26/120 (21.7%) neonates with CF and 19/26 (73.0%) required surgery. Prematurity was significantly associated with increased risk of MI and operative intervention (p-value 0.022 and p-value 0.016 respectively); lower birthweight was associated with operative intervention (p-value 0.039); genotype and echogenic bowel were associated with neither. Surgical data were available for 17/19 patients; median age at surgery was 2 days (IQR1-3), 4/17 had an atresia and 6/17 received an ostomy. Median NICU and hospital stays were 34.5 and 70 days while median time on TPN and time to ostomy reversal were 28.5 and 97 days, respectively. CONCLUSIONS: In patients with CF, prematurity and lower birthweight were identified as risk factors for meconium ileus and need for surgery. Specific genotypes and echogenic bowel were not predictors of either. LEVEL OF EVIDENCE: Level III.

No. 359-Obstetric Ultrasound Biological Effects and Safety.

OBJECTIVE: To review the biological effects and safety of obstetric ultrasound. OUTCOME: Outline the circumstances in which safety may be a concern with obstetric ultrasound. EVIDENCE: The 2005 version of this guideline was used as a basis and updated following a Medline search and review of relevant publications. Sources included guidelines and reports by Health Canada and the American Institute of Ultrasound in Medicine. VALUES: Review by principal author and the Diagnostic Imaging Committee of the SOGC. The quality of evidence and classification of recommendations have been adapted from the Report of the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS: Obstetric ultrasound should only be done for medical reasons, and exposure should be kept as low as reasonably achievable because of the potential for tissue heating. Higher energy is of particular concern in the following scenarios: Doppler studies (pulsed, colour, and power), first trimester ultrasound with a long trans-vesical path (>5 cm), second or third trimester exams when bone is in the focal zone, when scanning tissue with minimal perfusion (embryonic), or in patients who are febrile. Operators can minimize risk by limiting dwell time and exposure to critical structures. It is also important to be aware of equipment-generated exposure information.

Effect of Folic Acid Food Fortification in Canada on Congenital Heart Disease Subtypes.

BACKGROUND: Previous studies have yielded inconsistent results for the effects of periconceptional multivitamins containing folic acid and of folic acid food fortification on congenital heart defects (CHDs). METHODS: We carried out a population-based cohort study (N=5 901 701) of all live births and stillbirths (including late-pregnancy terminations) delivered at ≥20 weeks' gestation in Canada (except Québec and Manitoba) from 1990 to 2011. CHD cases were diagnosed at birth and in infancy (n=72 591). We compared prevalence rates and temporal trends in CHD subtypes before and after 1998 (the year that fortification was mandated). An ecological study based on 22 calendar years, 14 geographic areas, and Poisson regression analysis was used to quantify the effect of folic acid food fortification on nonchromosomal CHD subtypes (n=66 980) after controlling for changes in maternal age, prepregnancy diabetes mellitus, preterm preeclampsia, multiple birth, and termination of pregnancy. RESULTS: The overall birth prevalence rate of CHDs was 12.3 per 1000 total births. Rates of most CHD subtypes decreased between 1990 and 2011 except for atrial septal defects, which increased significantly. Folic acid food fortification was associated with lower rates of conotruncal defects (adjusted rate ratio [aRR], 0.73, 95% confidence interval [CI], 0.62-0.85), coarctation of the aorta (aRR, 0.77; 95% CI, 0.61-0.96), ventricular septal defects (aRR, 0.85; 95% CI, 0.75-0.96), and atrial septal defects (aRR, 0.82; 95% CI, 0.69-0.95) but not severe nonconotruncal heart defects (aRR, 0.81; 95% CI, 0.65-1.03) and other heart or circulatory system abnormalities (aRR, 0.98; 95% CI, 0.89-1.11). CONCLUSIONS: The association between food fortification with folic acid and a reduction in the birth prevalence of specific CHDs provides modest evidence for additional benefit from this intervention.

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).