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Background: Cannabis use among pregnant and lactating people is increasing, despite clinical evidence showing that cannabis use may be associated with low birth weight and childhood developmental deficits. Our objective was to understand why pregnant and lactating people use cannabis and how these motivations change across perinatal stages. Methods: Using qualitative, constructivist grounded theory methodology, we conducted telephone and virtual interviews with 52 individuals from across Canada. We selected participants using maximum variation and theoretical sampling. They were eligible if they had been pregnant or lactating within the past year and had decided to continue, cease or decrease their cannabis use during the perinatal period. Results: We identified 3 categories of reasons that people use cannabis during pregnancy and lactation: sensation-seeking for fun and enjoyment; symptom management of chronic conditions and conditions related to pregnancy; and coping with the unpleasant, but nonpathologized, experiences of life. Before pregnancy, participants endorsed reasons for using cannabis in these 3 categories in similar proportions, with many offering multiple reasons for use. During pregnancy, reasons for use shifted primarily to symptom management. During lactation, reasons returned to resemble those expressed before pregnancy. Interpretation: In this study, we showed that pregnant and lactating people use cannabis for many reasons, particularly for symptom management. Reasons for cannabis use changed across reproductive stages. The dynamic nature of the reasons for use across stages speaks to participant perception of benefits and risks, and perhaps a desire to cast cannabis use during pregnancy as therapeutic because of perceived stigma.

Background In women, preeclampsia has a known association with increased long-term cardiovascular morbidity and mortality. However, it is unknown whether it is associated with increased postoperative cardiovascular morbidity and mortality in women. We aimed to determine if preeclampsia is an independent risk factor for myocardial injury after noncardiac surgery (MINS) and postoperative 30-day mortality. Methods This study was a large international multicentre cohort study of a representative sample of 40,004 patients recruited from August 2007 to November 2013. Participants were ≥ 45 years of age and underwent inpatient noncardiac surgery. Within this cohort, our study examined women with a history of pregnancy. Using multivariable models, we explored the association between a history of pregnancy affected by preeclampsia and our primary outcome of MINS and secondary outcome of postoperative mortality within 30 days. MINS was defined as prognostically relevant myocardial injury due to ischemia that occurred during or within 30 days after noncardiac surgery. Results Analyses were restricted to the 13,902 participants with a history of pregnancy. Among these women, 976 (7.0%) had a history of preeclampsia. A history of preeclampsia was associated with an increased risk of MINS, with an adjusted hazard ratio of 1.26 (95% confidence interval 1.03-1.53; P = 0.02). Preeclampsia was not significantly associated with 30-day mortality. Conclusions Preeclampsia is a risk factor for MINS and should be considered in the preoperative cardiovascular risk assessment of women.

Background Perinatal cannabis use is increasing, and clinician counselling is an important aspect of reducing the potential harm of cannabis use during pregnancy and lactation. To understand current counselling practices, we conducted a systematic review and integrative mixed-methods synthesis to determine “how do perinatal clinicians respond to pregnant and lactating patients who use cannabis?” Methods We searched 6 databases up until 2021-05-31. Eligible studies described the attitudes, perceptions, or beliefs of perinatal clinician about cannabis use during pregnancy or lactation. Eligible clinicians were those whose practice particularly focusses on pregnant and postpartum patients. The search was not limited by study design, geography, or year. We used a convergent integrative analysis method to extract relevant findings for inductive analysis. Results Thirteen studies were included; describing perspectives of 1,366 clinicians in 4 countries. We found no unified approach to screening and counselling. Clinicians often cited insufficient evidence around the effects of perinatal cannabis use and lacked confidence in counselling about use. At times, this meant clinicians did not address cannabis use with patients. Most counselled for cessation and there was little recognition of the varied reasons that patients might use cannabis, and an over-reliance on counselling focussed on the legal implications of use. Conclusion Current approaches to responding to cannabis use might result in inadequate counselling. Counselling may be improved through increased education and training, which would facilitate conversations to mitigate the potential harm of perinatal cannabis use while recognizing the benefits patients perceive.

Objectives: Pregnant women prioritize the health of their pregnancy, and weight gain contributes to the pregnancy’s health. Women encounter different messages about gestational weight gain from various sources that can be confusing. This study aimed to increase our understanding of the processes influencing how women experience the gestational weight gain advice they receive. Methods: Grounded theory methodology was chosen. Women receiving prenatal care in a primary care setting were invited to participate in one-on-one interviews. Results: All fifteen participants had high educational attainment, fourteen were Caucasian, and five had an elevated pre-pregnancy body mass index. Six interconnected themes emerged from the data: (1) striving to have a healthy pregnancy; (2) experiencing influences; (3) feeling worried; (4) Managing ambiguity; (5) trusting a source of information; and (6) feeling relief. Conclusions for Practice: Physicians are perceived by pregnant women to be a source of trusted information about gestational weight gain and are therefore in a strategic position to help women achieve healthy weight gain during pregnancy.

OBJECTIVE We aimed to quantify the risk of future maternal type 2 diabetes mellitus (T2DM) in women with gestational diabetes mellitus (GDM) based on the type and number of abnormal 75-g oral glucose tolerance test (OGTT) values and the diagnostic criteria used for the diagnosis of GDM. RESEARCH DESIGN AND METHODS We conducted a population-based retrospective cohort study of all nulliparous women with a live singleton birth who underwent testing for GDM using a 75-g OGTT in Ontario, Canada (2007–2017). We estimated the incidence rate (per 1,000 person-years), overall risk (expressed as adjusted hazard ratio [aHR]), and risk at 5 years after the index pregnancy of future maternal T2DM. Estimates were stratified by the type and number of abnormal OGTT values, as well as by the diagnostic criteria for GDM (Diabetes Canada [DC] vs. International Association of the Diabetes and Pregnancy Study Groups [IADPSG] criteria). RESULTS A total of 55,361 women met the study criteria. The median duration of follow-up was 4.4 (interquartile range 2.8–6.3; maximum 10.3) years. Using women without GDM as reference (incidence rate 2.18 per 1,000 person-years), women with GDM were at an increased risk of future T2DM; this risk was greater when using the DC compared with the IADPSG criteria (incidence rate 18.74 [95% CI 17.58–19.90] vs. 14.07 [95% CI 13.24–14.91] per 1,000 person-years, respectively). The risk of future maternal T2DM increased with the number of abnormal OGTT values and was highest for women with three abnormal values (incidence rate 49.93 per 1,000 person-years; aHR 24.57 [95% CI 21.26–28.39]). The risk of future T2DM was also affected by the type of OGTT abnormality: women with an abnormal fasting value had the greatest risk, whereas women with an abnormal 2-h value had the lowest risk (aHR 14.09 [95% CI 12.46–15.93] vs. 9.22 [95% CI 8.19–10.37], respectively). Similar findings to those described above were observed when the risk of T2DM at a fixed time point of 5 years after the index pregnancy was considered as the outcome of interest. CONCLUSIONS In women with GDM, individualized information regarding the future risk of T2DM can be provided based on the type and number of abnormal OGTT values, as well as the diagnostic criteria used for the diagnosis of GDM.

Context The optimal 50 g-glucose challenge test (GCT) cutoff for the diagnosis of gestational diabetes mellitus (GDM) in twin pregnancies is unknown. Objective This work aimed to explore the screening accuracy of the 50 g-GCT and its correlation with the risk of large for gestational age (LGA) newborn in twin compared to singleton pregnancies. A population-based retrospective cohort study (2007-2017) was conducted in Ontario, Canada. Participants included patients with a singleton (n = 546 892 [98.4%]) or twin (n = 8832 [1.6%]) birth who underwent screening for GDM using the 50 g-GCT. Methods We compared the screening accuracy, risk of GDM, and risk of LGA between twin and singleton pregnancies using various 50 g-GCT cutoffs. Results For any given 50 g-GCT result, the probability of GDM was higher (P = .0.007), whereas the probability of LGA was considerably lower in the twin compared with the singleton group, even when a twin-specific growth chart was used to diagnose LGA in the twin group (P Conclusion The screening performance of the 50 g-GCT for GDM and its correlation with LGA differ between twin and singleton pregnancies.

IntroductionSouth Asians are more likely to develop gestational diabetes mellitus (GDM) than white Europeans. Diet and lifestyle modifications may prevent GDM and reduce undesirable outcomes in both the mother and offspring. Our study seeks to evaluate the effectiveness and participant acceptability of a culturally tailored, personalised nutrition intervention on the glucose area under the curve (AUC) after a 2-hour 75 g oral glucose tolerance test (OGTT) in pregnant women of South Asian ancestry with GDM risk factors.Methods and analysisA total of 190 South Asian pregnant women with at least 2 of the following GDM risk factors—prepregnancy body mass index>23, age>29, poor-quality diet, family history of type 2 diabetes in a first-degree relative or GDM in a previous pregnancy will be enrolled during gestational weeks 12–18, and randomly assigned in a 1:1 ratio to: (1) usual care, plus weekly text messages to encourage walking and paper handouts or (2) a personalised nutrition plan developed and delivered by a culturally congruent dietitian and health coach; and FitBit to track steps. The intervention lasts 6–16 weeks, depending on week of recruitment. The primary outcome is the glucose AUC from a three-sample 75 g OGTT 24–28 weeks’ gestation. The secondary outcome is GDM diagnosis, based on Born-in-Bradford criteria (fasting glucose>5.2 mmol/L or 2 hours post load>7.2 mmol/L).Ethics and disseminationThe study has been approved by the Hamilton Integrated Research Ethics Board (HiREB #10942). Findings will be disseminated among academics and policy-makers through scientific publications along with community-orientated strategies.Trial registration numberNCT03607799.

IMPORTANCE: Animal studies have found that antenatal corticosteroids affect many organs across multiple stages of life. However, the long-term outcomes in human children are not well understood. OBJECTIVE: To conduct a systematic review and meta-analysis of long-term outcomes associated with preterm exposure to antenatal corticosteroids compared with no exposure in all children as well as children with preterm and full-term birth. DATA SOURCES: Academic databases were searched for articles published from January 1, 2000, to October 29, 2021, including Ovid MEDLINE, Ovid Embase, PsycInfo, CINAHL (Cumulative Index of Nursing and Allied Health Literature), Web of Science, ClinicalTrials.gov, and Google Scholar. References of articles were also searched for relevant studies. STUDY SELECTION: Randomized clinical trials (RCTs), quasi-RCTs, and cohort studies that assessed long-term neurodevelopmental, psychological, or other outcomes at 1 year or older in those who had preterm exposure to antenatal corticosteroids were included. No language restrictions were set. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted data using a piloted data extraction form. Data on study population, pregnancy characteristics, exposure to antenatal corticosteroids, and outcomes were collected. Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines were followed, and random-effects models were used for the meta-analysis. MAIN OUTCOMES AND MEASURES: The primary outcome was an author-defined composite of any adverse neurodevelopmental and/or psychological disorder. The secondary outcomes included specific measures of psychological disorders; neurodevelopmental delay; and anthropometric, metabolic, and cardiorespiratory outcomes. RESULTS: A total of 30 studies met the inclusion criteria, and involved more than 1.25 million children who were at least 1 year of age when the outcomes were assessed. Exposure to a single course of antenatal corticosteroids for children with extremely preterm birth was associated with a significant reduction in risk of neurodevelopmental impairment (adjusted odds ratio, 0.69 [95% CI, 0.57-0.84]; I(2) = 0%; low certainty). For children with late-preterm birth, exposure to antenatal corticosteroids was associated with a higher risk of investigation for neurocognitive disorders (n = 25 668 children; adjusted hazard ratio [aHR], 1.12 [95% CI, 1.05-1.20]; low certainty). For children with full-term birth, exposure to antenatal corticosteroids was associated with a higher risk of mental or behavioral disorders (n = 641 487 children; aHR, 1.47 [95% CI, 1.36-1.60]; low certainty) as well as proven or suspected neurocognitive disorders (n = 529 205 children; aHR, 1.16 [95% CI, 1.10-1.21]; low certainty). CONCLUSIONS AND RELEVANCE: Results of this study showed that exposure to a single course of antenatal corticosteroids was associated with a significantly lower risk of neurodevelopmental impairment in children with extremely preterm birth but a significantly higher risk of adverse neurocognitive and/or psychological outcomes in children with late-preterm and full-term birth, who made up approximately half of those with exposure to antenatal corticosteroids. The findings suggest a need for caution in administering antenatal corticosteroids.

Perinatal cannabis use is increasing, and clinician counselling is an important aspect of reducing the potential harm of cannabis use during pregnancy and lactation. To understand current counselling practices, we conducted a systematic review and integrative mixed-methods synthesis to determine "how do perinatal clinicians respond to pregnant and lactating patients who use cannabis?"We searched 6 databases up until 2021-05-31. Eligible studies described the attitudes, perceptions, or beliefs of perinatal clinician about cannabis use during pregnancy or lactation. Eligible clinicians were those whose practice particularly focusses on pregnant and postpartum patients. The search was not limited by study design, geography, or year. We used a convergent integrative analysis method to extract relevant findings for inductive analysis.Thirteen studies were included; describing perspectives of 1,366 clinicians in 4 countries. We found no unified approach to screening and counselling. Clinicians often cited insufficient evidence around the effects of perinatal cannabis use and lacked confidence in counselling about use. At times, this meant clinicians did not address cannabis use with patients. Most counselled for cessation and there was little recognition of the varied reasons that patients might use cannabis, and an over-reliance on counselling focussed on the legal implications of use.Current approaches to responding to cannabis use might result in inadequate counselling. Counselling may be improved through increased education and training, which would facilitate conversations to mitigate the potential harm of perinatal cannabis use while recognizing the benefits patients perceive.Cannabis use during pregnancy and breastfeeding is common and understanding current physician counselling approaches is important to identify gaps and to make suggestions for practice. We conducted a systematic review of the literature to understand how physicians respond to pregnant or breastfeeding patients who use cannabis. We found 13 eligible articles in our review and our analysis showed that there was no common approach to screening and counselling patients. Physicians often described needing more training and education to support their confidence. Additionally, physicians often did not address the various medical reasons for which patients might use cannabis during pregnancy and breastfeeding. We suggest that counselling approaches may be improved through increased education and training. This could facilitate conversations to help mitigate the potential harm of cannabis use while recognizing the benefits patients perceive and thus establish strong patient–physician relationships.

Rates of perinatal cannabis use are rising, despite clinical evidence about the potential for harm. Accordingly, pregnant and lactating people who perceive a benefit from cannabis use may have a difficult time making informed decisions about cannabis use.We conducted a systematic review of mixed-methods research to synthesize existing knowledge on the perspectives of pregnant people and their partners about cannabis use in pregnancy. Six health and social science databases were searched up until May 30, 2021. There were no methodological, time, or geographic limits applied. We employed a convergent integrative approach to the inductive analysis of findings from all studies.We identified 26 studies describing views of 17,781 pregnant and postpartum people about cannabis use in pregnancy. No studies describing the views of partners were identified, and only one study specifically addressed the perspectives of lactating people. Comparative analysis revealed that whether cannabis was studied alone or grouped with other substances resulted in significant diversity in descriptions of participant decision-making priorities and perceptions of risks and benefits. Studies of cannabis alone demonstrated a complex decision-making process whereby perceived benefits are balanced against the available information about risk, which is often unclear and uncertain. Clear and helpful information was difficult to identify, and health care providers were not described as a helpful and trusted resource for decision-making.Decision-making about cannabis use is difficult for pregnant and lactating people who perceive a benefit from this use, although this decisional difficulty is seldom reflected in studies that examine cannabis as one of multiple substances that pregnant or lactating people may use. Our review suggests several approaches clinicians may take to encourage open and supportive conversations to facilitate informed decisions about cannabis use during the perinatal period.

ObjectiveMultiple myeloma (MM)-related morbidity has a profound effect on quality of life (QoL), and immune function, but few studies have prospectively examined the impact of COVID-19 pandemic and attendant vaccination on both immunity and QoL of patients with MM. We aimed to characterise these effects in a prospective cohort study. DesignWe initiated a prospective national cohort study of patients with MM from start of the second wave of SARS CoV-2 infections in December 2020 and resultant COVID lockdown in the United Kingdom. We assessed current myeloma status, history of COVID19 symptoms, testing and vaccination including response using the rudystudy.org platform. In addition, healthcare resource use, mental and social well being and loneliness (Lubben scale) from the start of the COVID-19 pandemic were assessed. ParticipantsWe report data from the first one hundred and nine adults with MM who completed the questionnaires and the first round of blood testing in the cohort. ResultsFive patients (4.5%) had COVID-19 infection confirmed by history and/or testing (Nucleocapsid antibody). Up to 98% of patients shielded completely or partially during both waves of the pandemic, with 18% of patients consequently changing antimyeloma therapy in the shielding period. Using the Lubben scale, 21/99 (21.2 %) reported social isolation. Using HADS scale 23.1% of patients reported symptoms of mild to moderate anxiety or mild to moderate depression during this period. Humoral immune response (spike ab) tested 3 weeks after first vaccination was detected in 17/28 (60%) patients. ConclusionMyeloma patients shielded during waves of the pandemic with significant change to therapy, low level natural COVID-19 infection (4%) and social isolation. Humoral response following the first dose of COVID-19 vaccine is lower than that reported in non-myeloma cohorts. What is already known on this topicLimited published data exist on the effect of the COVID-19 pandemic on myeloma patients. Post first vaccine response in myeloma patients has been reported in a small number of patients from two studies ranging from 25 % to 56%. What this study addsThis study reports myeloma patients shielded during waves of the pandemic and demonstrates consequent significant social isolation and changes to therapy. Low level natural COVID-19 infection (4%) was noted in the study and humoral response following first dose of COVID-19 vaccine was lower than that reported in non-myeloma cohorts.

Background: People whose singleton pregnancy is affected by hypertensive disorders of pregnancy (HDP) are at risk of future cardiovascular disease. It is unclear, however, whether this association can be extrapolated to twin pregnancies. We aimed to compare the association between HDP and future cardiovascular disease after twin and singleton pregnancies. Methods: We conducted a population-based retrospective cohort study that included nulliparous people in Ontario, Canada, 1992–2017. We compared the future risk of cardiovascular disease among pregnant people from the following 4 groups: those who delivered a singleton without HDP (referent) and with HDP, and those who delivered twins either with or without HDP. Results: The populations of the 4 groups were as follows: 1 431 651 pregnant people in the singleton birth without HDP group; 98 631 singleton birth with HDP; 21 046 twin birth without HDP; and 4283 twin birth with HDP. The median duration of follow-up was 13 (interquartile range 7–20) years. The incidence rate of cardiovascular disease was lowest among those with a singleton or twin birth without HDP (0.72 and 0.74 per 1000 person-years, respectively). Compared with people with a singleton birth without HDP, the risk of cardiovascular disease was highest among those with a singleton birth and HDP (1.47 per 1000 person-years; adjusted hazard ratio [HR] 1.81 [95% confidence interval (CI) 1.72–1.90]), followed by people with a twin pregnancy and HDP (1.07 per 1000 person-years; adjusted HR 1.36 [95% CI 1.04–1.77]). The risk of the primary outcome after a twin pregnancy with HDP was lower than that after a singleton pregnancy with HDP (adjusted HR 0.74 [95% CI 0.57–0.97]), when compared directly. Interpretation: In a twin pregnancy, HDP are weaker risk factors for postpartum cardiovascular disease than in a singleton pregnancy.

Background The primary aim of this study was to examine weight gain during pregnancy and associated adverse outcomes across different types of antenatal health care providers. Our research question examined whether type of antenatal health care provider (family physician, obstetrician, midwife, or family physician plus obstetrician) was associated with differing rates of excess or inadequate weight gain and associated adverse outcomes including being large for gestational age, being small for gestational age, cesarean delivery and preterm birth. Methods This retrospective cohort study used data from the Better Outcomes Registry & Network Information System, 2014-2016, for singleton hospital births at 20-42 weeks' gestation in Ontario. We calculated descriptive statistics to summarize patient characteristics and outcomes by antenatal health care provider. We calculated crude and adjusted relative risks with 95% confidence intervals (CIs) for the exposure (weight gain during pregnancy) relative to each secondary outcome by health care provider. We calculated population attributable fractions with 95% CIs to assess the proportion of secondary outcomes that could be prevented if inadequate or excess weight gain (according to the 2009 Institute of Medicine guidelines) were removed by health care provider. Results The final cohort consisted of 231 697 pregnancies, of which 26 043 (11.2%), 136 994 (59.1%), 32 262 (13.9%) and 36 298 (15.7%) were managed by a family physician, obstetrician, midwife, and family physician plus obstetrician, respectively. Rates of weight gain below, within or above recommended levels were 31 742 (13.7%), 71 826 (31.0%) and 128 128 (55.3%), respectively, and did not differ across health care provider groups. No difference was observed in rates of secondary outcomes according to weight gain across health care providers. Excess weight gain was associated with a significant risk of being large for gestational age and cesarean delivery, and inadequate weight gain was associated with an increased risk of being small for gestational age and preterm birth. The population attributable fractions indicated a pronounced contribution of excess weight gain to being large for gestational age across all health care provider groups. Interpretation Weight gain during pregnancy and rates of associated secondary outcomes did not differ according to antenatal health care provider. This suggests a need for further research exploring counselling techniques and strategies for all types of antenatal health care providers to use in order to promote optimal weight gain during pregnancy.

Objectif Évaluer l’effet du clampage retardé du cordon et de la traite du cordon ombilical sur les risques de mortalité et de morbidité maternelles et néonatales en contexte de grossesses monofœtale ou gémellaire. Population cible Femmes enceintes dont la grossesse monofœtale ou gémellaire est à terme ou avant terme. Bénéfices, risques et coûts Chez les prématurés de grossesse monofœtale, le clampage retardé de 60 à 120 secondes idéalement, mais d’au moins 30 secondes, réduit le risque de mortalité et de morbidité. Chez les jumeaux prématurés, le clampage retardé est associé à certains bénéfices. Chez les nourrissons de grossesse monofœtale à terme, le clampage retardé de 60 secondes améliore les paramètres hématologiques. Chez les grands prématurés, la traite du cordon ombilical augmente le risque d’hémorragie intraventriculaire. Données probantes Une recherche a été effectuée au moyen des bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu’à mars 2020, à partir de termes MeSH et de mot-clés liés au clampage retardé du cordon et à la traite du cordon ombilical. Le présent document est un résumé des données probantes et non pas une revue méthodologique. Méthodes de validation Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d’évaluation, de développement et d’évaluation (GRADE). Voir l’annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l’interprétation des recommandations fortes et conditionnelles [faibles]).

Objective To assess the impact of deferred (delayed) cord clamping (DCC) and umbilical cord milking in singleton and twin gestations on maternal and infant mortality and morbidity. Target Population Women who are pregnant with preterm or term singletons or twins. Benefits, Harms, and Costs In preterm singletons, DCC for (ideally) 60 to 120 seconds, but at least for 30 seconds, reduces infant risk of mortality and morbidity. DCC in preterm twins is associated with some benefits. In term singletons, DCC for 60 seconds improves hematological parameters. In very preterm infants, umbilical cord milking increases risk for intraventricular hemorrhage. Evidence Searches of Medline, PubMed, Embase, and the Cochrane Library from inception to March 2020 were undertaken using Medical Subject Heading (MeSH) terms and key words related to deferred cord clamping and umbilical cord milking. 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 conditional [weak] recommendations).

ObjectiveMultiple myeloma (MM)-related morbidity has a profound effect on quality of life (QoL), and immune function, but few studies have prospectively examined the impact of COVID-19 pandemic and attendant vaccination on both immunity and QoL of patients with MM. We aimed to characterise these effects in a prospective cohort study.DesignWe initiated a prospective national cohort study of patients with MM from start of the second wave of SARS CoV-2 infections in December 2020 and resultant COVID lockdown in the United Kingdom. We assessed current myeloma status, history of COVID19 symptoms, testing and vaccination including response using the rudystudy.org platform. In addition, healthcare resource use, mental and social well being and loneliness (Lubben scale) from the start of the COVID-19 pandemic were assessed.ParticipantsWe report data from the first one hundred and nine adults with MM who completed the questionnaires and the first round of blood testing in the cohort.ResultsFive patients (4.5%) had COVID-19 infection confirmed by history and/or testing (Nucleocapsid antibody). Up to 98% of patients shielded completely or partially during both waves of the pandemic, with 18% of patients consequently changing antimyeloma therapy in the shielding period. Using the Lubben scale, 21/99 (21.2 %) reported social isolation. Using HADS scale 23.1% of patients reported symptoms of mild to moderate anxiety or mild to moderate depression during this period. Humoral immune response (spike ab) tested 3 weeks after first vaccination was detected in 17/28 (60%) patients.ConclusionMyeloma patients shielded during waves of the pandemic with significant change to therapy, low level natural COVID-19 infection (4%) and social isolation. Humoral response following the first dose of COVID-19 vaccine is lower than that reported in non-myeloma cohorts.What is already known on this topicLimited published data exist on the effect of the COVID-19 pandemic on myeloma patients. Post first vaccine response in myeloma patients has been reported in a small number of patients from two studies ranging from 25 % to 56%.What this study addsThis study reports myeloma patients shielded during waves of the pandemic and demonstrates consequent significant social isolation and changes to therapy. Low level natural COVID-19 infection (4%) was noted in the study and humoral response following first dose of COVID-19 vaccine was lower than that reported in non-myeloma cohorts.

Objective Clinical detection and management of chorioamnionitis is challenging given the gold-standard for diagnosis remains placental pathology, the results of which are only available after delivery. Moreover, recommended diagnostic criteria for clinical chorioamnionitis have evolved over time. The goal of this study was to describe trends and differences in chorioamnionitis diagnostic and management practices in Canada. Methods We surveyed obstetric care providers participating in the Canadian Preterm Birth Network. Questionnaires were distributed electronically to all 29 sites and completed by 1 maternal–fetal medicine investigator at each site. Results The response rate was 82.8% (n = 24). There was considerable variation in the clinical criteria used to diagnose chorioamnionitis with 9 of 22 sites stating this occurs “frequently” or “very frequently.” Isolated fever was “always” or “most of the time” used as an indication to start empiric antibiotic therapy in 14 of 24 sites, and 21 of 23 sites used the same diagnostic criteria for term and preterm deliveries. Placental histology (15 sites) and white blood cell count (14 sites) were the most common clinical tests performed to confirm chorioamnionitis. A combination of ampicillin and aminoglycoside antibiotics was used at 12 sites. Another frequently used antibiotic therapy was cefazolin and metronidazole (4 sites). Conclusion There is a wide variation in practices for the diagnosis and management of chorioamnionitis across Canada. The results of this study will guide efforts to improve and standardize the management of this condition.

Background Previous studies have noted traditional physical, demographic, and obstetrical predictors of inadequate or excess gestational weight gain, but the roles of psychological and behavioral factors are not well established. Few interventions targeting traditional factors of gestational weight gain have been successful, necessitating exploration of new domains. The objective of this study was to identify novel psychological and behavioral factors, along with physical, demographic, and obstetrical factors, associated with gestational weight gain that is discordant with the 2009 Institute of Medicine guidelines (inadequate or excess gain). Methods We recruited English-speaking women with a live singleton fetus at 8 to 20 weeks of gestation who received antenatal care from 12 obstetrical, family medicine, and midwifery clinics. A questionnaire was used to collect information related to demographic, physical, obstetrical, psychological, and behavioural factors anticipated to be related to weight gain. The association between these factors and total gestational weight gain, classified as inadequate, appropriate, and excess, was examined using stepwise multinomial logistic regression. Results Our study population comprised 970 women whose baseline data were obtained at a mean of 14.8 weeks of gestation ±3.4 weeks (standard deviation). Inadequate gestational weight gain was associated with obesity, planned gestational weight gain (below the guidelines or not reported), anxiety, and eating sensibly when with others but overeating when alone, while protective factors were frequent pregnancy-related food cravings and preferring an overweight or obese body size image. Excess gestational weight gain was associated with pre-pregnancy overweight or obese body mass index, planned gestational weight gain (above guidelines), frequent eating in front of a screen, and eating sensibly when with others but overeating when alone, while a protective factor was being underweight pre-pregnancy. Conclusions In addition to commonly studied predictors, this study identified psychological and behavioral factors associated with inadequate or excess gestational weight gain. Factors common to both inadequate and excessive gestational weight gain were also identified, emphasizing the multidimensional nature of the contributors to guideline-discordant weight gain.

CONTEXT: Deferred cord clamping (DCC) saves lives. It reduces extremely preterm infants’ mortality by 30%, yet a minority of eligible infants receive it. This may in part be due to lack of awareness or confidence in evidence, or conflicting or vague guidelines. OBJECTIVE: To systematically review clinical practice guidelines and other statements on DCC and cord milking. DATA SOURCES: Ten academic and guideline databases were searched. STUDY SELECTION: Clinical practice guidelines and other statements (position statements and consensus statements) providing at least 1 recommendation on DCC or umbilical cord milking among preterm or term infants were included. DATA EXTRACTION: Data from included statements were extracted by 2 independent reviewers, and discrepancies were resolved through consensus. Guideline quality was appraised with modified Appraisal of Guidelines for Research and Evaluation II and Appraisal of Guidelines for Research and Evaluation Recommendation Excellence tools. RESULTS: Forty-four statements from 35 organizations were included. All endorsed DCC for uncompromised preterm infants, and 11 cautiously stated that cord milking may be considered when DCC is infeasible. Only half (49%) of the recommendations on the optimal duration of DCC were supported by high-quality evidence. Only 8% of statements cited a mortality benefit of DCC for preterm infants. LIMITATIONS: Because systematic reviews of guidelines are relatively novel, there are few tools to inform study execution; however, we used the Appraisal of Guidelines for Research and Evaluation II and the Appraisal of Guidelines for Research and Evaluation Recommendation Excellence to assess quality and were methodologically informed by previous systematic reviews of guidelines. CONCLUSIONS: Statements worldwide clearly encouraged DCC. Their implementability would benefit from noting the preterm mortality benefit of DCC and more granularity.

The archaic definition and registration processes for stillbirth currently prevalent in Canada impede both clinical care and public health. The situation is fraught because of definitional problems related to the inclusion of induced abortions at ≥20 weeks' gestation as stillbirths: widespread uptake of prenatal diagnosis and induced abortion for serious congenital anomalies has resulted in an artefactual temporal increase in stillbirth rates in Canada and placed the country in an unfavourable position in international (stillbirth) rankings. Other problems with the Canadian stillbirth definition and registration processes extend to the inclusion of fetal reductions (for multi-fetal pregnancy) as stillbirths, and the use of inconsistent viability criteria for reporting stillbirth. This paper reviews the history of stillbirth registration in Canada, provides a rationale for updating the definition of fetal death and recommends a new definition and improved processes for fetal death registration. The recommendations proposed are intended to serve as a starting point for reformulating issues related to stillbirth, with the hope that building a consensus regarding a definition and registration procedures will facilitate clinical care and public health.RéSUMé: La définition et les méthodes d’enregistrement archaïques des mortinaissances qui prévalent actuellement au Canada entravent à la fois les soins cliniques et la santé publique. La situation est délicate à cause des problèmes de définition que pose l’inclusion des avortements provoqués à ≥ 20 semaines de gestation parmi les mortinaissances : le recours généralisé au diagnostic prénatal et les avortements provoqués en cas d’anomalies congénitales graves ont entraîné une augmentation temporelle artéfactuelle des taux de mortinatalité au Canada et placé le pays dans une position défavorable dans les classements internationaux (de la mortinatalité). Les autres problèmes dans la définition et les méthodes d’enregistrement canadiennes des mortinaissances sont l’inclusion de la réduction fœtale (pour les grossesses multifœtales) parmi les mortinaissances et l’emploi de critères de viabilité inconsistants pour déclarer les mortinaissances. Nous examinons ici l’histoire de l’enregistrement des mortinaissances au Canada, nous justifions une révision possible de la définition de la mort fœtale et nous recommandons une nouvelle définition et des méthodes d’enregistrement améliorées des morts fœtales. Les recommandations proposées se veulent un point de départ à une reformulation des questions liées à la mortinatalité, dans l’espoir que l’établissement d’un consensus sur une définition et sur les méthodes d’enregistrement facilitera les soins cliniques et la santé publique.

To assess the impact of deferred (delayed) cord clamping (DCC) and umbilical cord milking in singleton and twin gestations on maternal and infant mortality and morbidity.Women who are pregnant with preterm or term singletons or twins.In preterm singletons, DCC for (ideally) 60 to 120 seconds, but at least for 30 seconds, reduces infant risk of mortality and morbidity. DCC in preterm twins is associated with some benefits. In term singletons, DCC for 60 seconds improves hematological parameters. In very preterm infants, umbilical cord milking increases risk for intraventricular hemorrhage.Searches of Medline, PubMed, Embase, and the Cochrane Library from inception to March 2020 were undertaken using Medical Subject Heading (MeSH) terms and key words related to deferred cord clamping and umbilical cord milking. This document represents an abstraction of the evidence rather than a methodological review.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 conditional [weak] recommendations).

Évaluer l'effet du clampage retardé du cordon et de la traite du cordon ombilical sur les risques de mortalité et de morbidité maternelles et néonatales en contexte de grossesses monofœtale ou gémellaire.Femmes enceintes dont la grossesse monofœtale ou gémellaire est à terme ou avant terme.Chez les prématurés de grossesse monofœtale, le clampage retardé de 60 à 120 secondes idéalement, mais d'au moins 30 secondes, réduit le risque de mortalité et de morbidité. Chez les jumeaux prématurés, le clampage retardé est associé à certains bénéfices. Chez les nourrissons de grossesse monofœtale à terme, le clampage retardé de 60 secondes améliore les paramètres hématologiques. Chez les grands prématurés, la traite du cordon ombilical augmente le risque d'hémorragie intraventriculaire.Une recherche a été effectuée au moyen des bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu'à mars 2020, à partir de termes MeSH et de mot-clés liés au clampage retardé du cordon et à la traite du cordon ombilical. Le présent document est un résumé des données probantes et non pas une revue méthodologique.Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]).

The growing prevalence of obesity is a concern for midwives. In Canada, the absence of regulatory standards, varying protocols and consultant preferences shape clinical decision making for the midwife and may lead to inconsistent practice. Our aim was to understand the barriers, enablers, and knowledge gaps that influenced experiences of midwives in Ontario, Canada when providing care to clients impacted by obesity.Mixed methods design using a sequential, explanatory approach. Surveys conducted with midwives were administered using an online platform, followed by semi-structured interviews to understand the perspectives elicited in the survey in greater detail. Interviews were audio recorded and transcribed verbatim. Survey data were analyzed using descriptive statistics, and thematic analysis was used for generating codes, categories and themes from the interview data.144 midwives completed the survey and 20 participated in an interview. The participants described their clinical management when caring for those with obesity which included considerations regarding additional tests/investigations, consultation and transfer of care, and place of birth. Up to 93% of surveyed midwives believed that clients with obesity were appropriate for midwifery-led care however there was less certainty about suitability as BMI increased to higher ranges such as45). The care management was influenced by beliefs and attitudes, knowledge, and system-level factors. Midwives experienced barriers such as inconsistent practices and role confusion, and felt ill equipped to care for pregnancies affected by obesity due to unclear guidelines.Overall, midwives believe clients with obesity are suitable for midwifery-led care due to its individualized, non-judgmental approach to care. Additional training for midwives and other obstetric care providers would be beneficial to help overcome barriers in providing effective care to pregnancies affected by obesity.

Background Repeat caesarean sections (CSs) are major contributors to the high rate of CS in Canada and globally. Women’s decisions to have a planned repeat CS (PRCS) or a trial of labour after CS (TOLAC) are influenced by their maternity care providers. This study explored factors maternity care providers consider when counselling pregnant women with a previous CS, eligible for a TOLAC, about delivery method. Methods A qualitative descriptive design was implemented. Semi-structured, one-to-one in-depth telephone interviews were conducted with 39 maternity care providers in Ontario, Canada. Participants were recruited at 2 maternity care conferences and with the use of snowball sampling. Interviews were audio recorded and transcribed verbatim. Data were uploaded into the data management software, NVIVO 10.0 and analyzed using qualitative content analysis. Results Participants consisted of 12 obstetricians, 13 family physicians and 14 midwives. Emergent themes, reflecting the factors maternity care providers considered when counselling on mode of delivery, were organized under the categories clinical/patient factors, health system factors and provider preferences. Maternity care providers considered clinical/patient factors, including women’s choice … with conditions, their assessment of women’s chances of a successful TOLAC, their perception of women’s risk tolerance, women’s preferred delivery method, and their perception of women’s beliefs and attitudes about childbirth. Additionally, providers considered health system factors which included colleague support for TOLAC and time needed to mount an emergency CS. Finally, provider factors emerged as considerations when counselling. They included provider preference for PRCS or TOLAC, provider scope of practice, financial incentives and convenience related to PRCS, past experiences with TOLAC and PRCS and providers’ perspectives on risk of TOLAC. Conclusion The findings highlight the multiplicity of factors maternity care providers consider when counselling women. Effectively addressing clinical, health care system and personal factors that influence counselling may help decrease non-medically indicated PRCS.

Background Despite ample clinical evidence that gaining excess weight in pregnancy results in negative health outcomes for women and infants, more than half of women in Western industrialized nations gain in excess of national guidelines. The influence of socio-demographic factors and weight gain is well-established but not causal; the influence of psychological factors may explain some of this variation. Methods This is the qualitative portion of an explanatory sequential mixed-methods study designed to identify predictive psychological factors of excess gestational weight gain (QUAN) and then explain the relevance of those factors (qual). For this portion of the study, we used a qualitative descriptive approach to elicit 39 pregnant women’s perspectives of gestational weight gain, specifically inquiring about factors determined as relevant to excess gestational weight gain by our previous predictive study. Women were interviewed in the latter half of their third trimester. Data were analyzed using a combination of unconstrained deductive content analysis to describe the findings relevant to the predictive factors and a staged inductive content analytic approach to examine the data without a focus on the predictive factors. Results Very few participants consistently made deliberate choices relevant to weight gain; most behaviour relevant to weight gain happened with in-the-moment decisions. These in-the-moment decisions were influenced by priorities, hunger, a consideration of the consequence of the decision, and accommodation of pregnancy-related discomfort. They were informed by the foundational information a woman had available to her, including previous experience and interactions with health care providers. The foundational information women used to make these decisions was often incomplete. While women were aware of the guidelines related to gestational weight gain, they consistently mis-applied them due to incorrect understanding of their own BMI. Only one woman was aware that weight gain was linked to maternal and infant health outcomes. Conclusions There is an important role for prenatal providers to provide the foundational information to positively influence in-the-moment decisions. Understanding how weight gain guidelines apply to one’s own pre-pregnancy BMI and comprehending the well-established link between gestational weight gain and health outcomes may help women prioritize healthy weight gain amongst many competing factors.

Objective To develop and validate a prediction model for excess pregnancy weight gain using early pregnancy factors. Design Prospective cohort study Setting We recruited from 12 obstetrical, family medicine, and midwifery centers in Ontario, Canada Participants We recruited English-speaking women with singleton pregnancies between 8+0–20+6 weeks. Of 1296 women approached, 1050 were recruited (81%). Of those, 970 women had complete data (970/1050, 92%) and were recruited at a mean of 14.8 weeks. Primary outcome measure We collected data on psychological, physical, and social factors and used stepwise logistic regression analysis to develop a multivariable model predicting our primary outcome of excess pregnancy weight gain, with random selection of 2/3 of women for training data and 1/3 for testing data. Results Nine variables were included in the final model to predict excess pregnancy weight gain. These included nulliparity, being overweight, planning excessive gain, eating in front of a screen, low self-efficacy regarding pregnancy weight gain, thinking family or friends believe pregnant women should eat twice as much as before pregnancy, being agreeable, and having emotion control difficulties. Training and testing data yielded areas under the receiver operating characteristic curve of 0.76 (95% confidence interval, 0.72 to 0.80) and 0.62 (95% confidence interval 0.56 to 0.68), respectively. Conclusions In this first validated prediction model in early pregnancy, we found that nine psychological, physical, and social factors moderately predicted excess pregnancy weight gain in the final model. This research highlights the importance of several predictors, including relatively easily modifiable ones such as appropriate weight gain plans and mindfulness during eating, and lays an important methodological foundation for other future prediction models.

Background Inappropriate gestational weight gain in pregnancy may negatively impact health outcomes for mothers and babies. While optimal gestational weight gain is often not acheived, effective counselling by antenatal health care providers is recommended. It is not known if gestational weight gain counselling practices differ by type of antenatal health care provider, namely, family physicians, midwives and obstetricians, and what barriers impede the delivery of such counselling. The objective of this study was to understand the counselling of family physicians, midwives and obstetricians in Ontario and what factors act as barriers and enablers to the provision of counselling about GWG. Methods Semi-structured interviews were conducted with seven family physicians, six midwives and five obstetricians in Ontario, Canada, where pregnancy care is universally covered. Convenience and purposive sampling techniques were employed. A grounded theory approach was used for data analysis. Codes, categories and themes were generated using NVIVO software. Results Providers reported that they offered gestational weight gain counselling to all patients early in pregnancy. Counselling topics included gestational weight gain targets, nutrition & exercise, gestational diabetes prevention, while dispelling misconceptions about gestational weight gain. Most do not routinely address the adverse outcomes linked to gestational weight gain, or daily caloric intake goals for pregnancy. The health care providers all faced similar barriers to counselling including patient attitudes, social and cultural issues, and accessibility of resources. Patient enthusiasm and access to a dietician motivated health care providers to provide more in-depth gestational weight gain counselling. Conclusion Reported gestational weight gain counselling practices were similar between midwives, obstetricians and family physicians. Antenatal knowledge translation tools for patients and health care providers are needed, and would seem to be suitable for use across all three types of health care provider specialties.

Background: Preterm birth (PTB) is a major cause of infant death globally. The rising rates of pre-pregnancy diabetes mellitus (D), obesity (O) and chronic hypertension (H) will place a significant burden on maternal-fetal health but their combined influence on PTB is unknown. Methods: Population-based cohort study, Ontario, Canada, April 1, 2012 to March 31 2016. Participants were 506,483 women with a singleton livebirth or stillbirth at > 20 weeks' gestation. The exposures of interest were D, O and H, individually, and in various combinations. The primary outcome was PTB at 241/7 to 366/7 weeks. PTB was further analyzed by spontaneous or provider-initiated, early (< 34 weeks) or late (34-37 weeks), and the co-presence of preeclampsia, large for gestational age (LGA), and small for gestational age (SGA) birthweight. Multivariable Poisson regression models with robust error variance were used to generate relative risks (RR), further adjusted for maternal age and parity (aRR). Population attributable fractions were then calculated for each of the outcomes by exposure state. Findings: Relative to women without D or O or H, the aRR for PTB were (3.09, 95% CI 2.80-3.40) with D + O, 6.34 (95% CI 5.15-7.81) with D + H, 2.96 (95% CI 2.70-3.24) with O + H, and 5.55 (95% CI 4.76-6.47) with D + O + H. In women with D + H, aRR was more pronounced for provider-initiated PTB (10.99, 95% CI 8.40-14.38) than for spontaneous PTB (3.05, 95% CI 1.92-4.85). Those with D + O + H had an aRR of 9.21 (95% CI 4.97-17.04) for PTB with an SGA newborn relative to those without D or O or H. Interpretation: Combinations of D, O and H significantly magnify the risk of PTB, especially provider-initiated PTB, and PTB with altered fetal growth or preeclampsia. These data may inform health policy and clinical decision-making both at the population and patient level. Funding: CIHR. Declaration of Interest: All authors report no conflict of interest Ethical Approval: Ethics approval was obtained from the St. Michael’s Hospital Research Ethics Board (REB # 16-345).

Environmental factors affecting development through embryogenesis, pregnancy, and infancy impact health through all subsequent stages of life. Known as the Developmental Origins of Health and Disease (DOHaD) hypothesis, this concept is widely accepted among health and social scientists. However, it is unclear whether DOHaD-based ideas are reaching the general public and/or influencing behaviour. This study thus investigated whether and under what circumstances pregnant people in Canada are familiar with DOHaD, and if DOHaD familiarity relates to eating behaviour. Survey responses from pregnant people from Hamilton, Canada, were used to assess respondents' knowledge of DOHaD (hereafter, DOHaDKNOWLEDGE) compared with their knowledge of more general pregnancy health recommendations (Pregnancy GuidelineKNOWLEDGE). The survey also characterized respondents' pregnancy diet quality and sociodemographic profiles. We fit two multiple, linear, mixed regression models to the data, one with DOHaDKNOWLEDGE score as the dependent variable and the other with diet quality score as the dependent. In both models, responses were clustered by respondents' neighbourhoods. Complete, internally consistent responses were available for 330 study-eligible respondents. Relative to Pregnancy GuidelineKNOWLEDGE, respondents had lower, more variable DOHaDKNOWLEDGE scores. Additionally, higher DOHaDKNOWLEDGE was associated with higher socio-economic position, older age, and lower parity, independent of Pregnancy GuidelineKNOWLEDGE. Diet quality during pregnancy was positively associated with DOHaDKNOWLEDGE, adjusting for sociodemographic factors. A subset of relatively high socio-economic position respondents was familiar with DOHaD. Greater familiarity with DOHaD was associated with better pregnancy diet quality, hinting that translating DOHaD knowledge to pregnant people may motivate improved pregnancy nutrition and thus later-life health for developing babies.

OBJECTIVES: To explore provincial variation in both excess and inadequate pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) and their impact on small- and large-for-gestational-age (SGA, LGA) infants. METHODS: Four provinces with a perinatal database capturing the required exposures participated: British Columbia (BC), Ontario (ON), Nova Scotia (NS), and Newfoundland and Labrador (NL). In multiple, concurrent retrospective studies, we included women ≥ 19 years, who gave birth from 22(+0) to 42(+6) weeks’ gestation, to a live singleton from April 2013–March 2014. From adjusted odds ratios, we calculated population attributable fractions (PAF) of SGA and LGA for BMI and GWG. RESULTS: The proportion of overweight and obese women increased from western to eastern Canada. In BC, ON, NS, and NL, the proportions of women who were overweight were 21.1%, 24.0%, 23.7%, and 25.4%, while obesity proportions were 14.2%, 18.1%, 24.2%, and 29.8%, respectively. Excess GWG affected 53.9%, 49.9%, 57.6%, and 65.6% of women, respectively. Excess GWG contributed to 29.5–42.5% of LGA, compared with the PAFs for overweight (6.8–12.0%) and obesity (13.2–20.6%). Inadequate GWG’s contribution to SGA (4.8–12.3%) was higher than underweight BMI’s (2.9–6.2%). CONCLUSION: In this interprovincial study, high and increasing proportions of women from west to east had excess pre-pregnancy BMI, and between half to two thirds had excess GWG. The contributions of GWG outside of recommendations to SGA and LGA were greater than that of low or high BMI. GWG is a potentially modifiable determinant of SGA and LGA across Canada. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.17269/s41997-018-0086-x) contains supplementary material, which is available to authorized users.

Impact of antenatal corticosteroid (ACS) in context of maternal body mass index (BMI) as it relates to neonatal outcomes remains unclear. We sought to evaluate effects of ACS on clinical outcomes of preterm infants based on maternal BMI.We performed a retrospective cohort study among neonates 23-33 weeks' GA at a tertiary neonatal intensive care unit from 2011 to 2015. Outcomes of neonates exposed to any ACS and pre-pregnancy maternal BMI ≥ 25 (N = 491) were compared with maternal BMI 25 (N = 484). A priori planned subgroup analyses based on ACS exposure (partial ACS; complete ACS ≤ 7 days prior to delivery (PTD); and complete ACS 7 days PTD) were conducted. Primary outcome was composite of mortality or any of moderate/severe bronchopulmonary dysplasia, severe neurologic injury, severe retinopathy of prematurity, necrotizing enterocolitis stage, or primary bloodstream infection.Preterm neonates with maternal BMI ≥ 25 (exposed to any ACS) were not at increased risk of composite outcome vs. BMI 25 (adjusted odd ratio (aOR) 1.03, 95% confidence interval (CI) 0.84-1.48), nor any individual neonatal morbidities. Similar findings were noted in subgroup analyses by type of ACS exposure.Impact of ACS on neonatal outcomes do not appear to be influenced by maternal BMI based on data from this cohort. However, further research is required to definitively elucidate the impact of BMI on ACS with regards to pharmacokinetics and neonatal outcomes.

Background Probiotics are living microorganisms that, when administered in adequate amounts, confer a health benefit. It has been speculated that probiotics might help prevent preterm birth, but in two previous systematic reviews possible major increases in this risk have been suggested. Our objective was to perform a systematic review and meta-analysis of the risk of preterm birth and other adverse pregnancy outcomes in pregnant women taking probiotics, prebiotics or synbiotics. Methods We searched six electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Web of Science’s Core collection and BIOSIS Preview) up to September 2016 and contacted authors for additional data. We included randomized controlled trials in which women with a singleton pregnancy received a probiotic, prebiotic or synbiotic intervention. Two independent reviewers extracted data using a piloted form and assessed the risk of bias using the Cochrane risk of bias tool. We used random-effects meta-analyses to pool the results. Results We identified 2574 publications, screened 1449 non-duplicate titles and abstracts and read 160 full text articles. The 49 publications that met our inclusion criteria represented 27 studies. No study used synbiotics, one used prebiotics and the rest used probiotics. Being randomized to take probiotics during pregnancy neither increased nor decreased the risk of preterm birth

Background Preterm birth (birth before 37 wk of gestation) occurs in about 8% of pregnancies in Canada and is associated with high mortality and morbidity rates that substantially affect infants, their families and the health care system. Our overall goal is to create a transdisciplinary platform, the Canadian Preterm Birth Network (CPTBN), where investigators, stakeholders and families will work together to improve childhood outcomes of preterm neonates. Methods Our national cohort will include 24 maternal-fetal/obstetrical units, 31 neonatal intensive care units and 26 neonatal follow-up programs across Canada with planned linkages to provincial health information systems. Three broad clusters of projects will be undertaken. Cluster 1 will focus on quality-improvement efforts that use the Evidence-based Practice for Improving Quality method to evaluate information from the CPTBN database and review the current literature, then identify potentially better health care practices and implement identified strategies. Cluster 2 will assess the impact of current practices and practice changes in maternal, perinatal and neonatal care on maternal, neonatal and neurodevelopmental outcomes. Cluster 3 will evaluate the effect of preterm birth on babies, their families and the health care system by integrating CPTBN data, parent feedback, and national and provincial database information in order to identify areas where more parental support is needed, and also generate robust estimates of resource use, cost and cost-effectiveness around preterm neonatal care. Interpretation These collaborative efforts will create a flexible, transdisciplinary, evaluable and informative research and quality-improvement platform that supports programs, projects and partnerships focused on improving outcomes of preterm neonates.

BACKGROUND Recent progesterone trials call for an update of previous syntheses of interventions to prevent preterm birth. OBJECTIVES To compare the relative effects of different types and routes of administration of progesterone, cerclage, and pessary at preventing preterm birth in at-risk women overall and in specific populations. SEARCH STRATEGY We searched Medline, EMBASE, CINAHL, Cochrane CENTRAL, and Web of Science up to 1 January 2018. SELECTION CRITERIA We included randomised trials of progesterone, cerclage or pessary for preventing preterm birth in at-risk singleton pregnancies. DATA COLLECTION AND ANALYSIS We used a piloted data extraction form and performed Bayesian random-effects network meta-analyses with 95% credibility intervals (CrI), as well as pairwise meta-analyses, rating the quality of the evidence using GRADE. MAIN RESULTS We included 40 trials (11 311 women). In at-risk women overall, vaginal progesterone reduced preterm birth

To examine rates and determinants of mother's own milk (MOM) feeding at hospital discharge in a cohort of infants born very preterm within the Canadian Neonatal Network (CNN).This was a population-based cohort study of infants born at33 weeks of gestation and admitted to neonatal intensive care units (NICUs) participating in the CNN between January 1, 2015, and December 31, 2018. We examined the rates and determinants of MOM use at discharge home among the participating NICUs. We used multivariable logistic regression analysis to identify independent determinants of MOM feeding.Among the 6404 infants born very preterm and discharged home during the study period, 4457 (70%) received MOM or MOM supplemented with formula. Rates of MOM feeding at discharge varied from 49% to 87% across NICUs. Determinants associated with MOM feeding at discharge were gestational age 29-32 weeks compared with26 weeks (aOR 1.56, 95% CI 1.25-1.93), primipara mothers (aOR 2.12, 95% CI 1.86-2.42), maternal diabetes (aOR 0.79, 95% CI 0.66-0.93), and maternal smoking (aOR 0.27, 95% CI 0.19-0.38). Receipt of MOM by day 3 of age was the major predictor of breast milk feeding at discharge (aOR 3.61, 95% CI 3.17-4.12).Approximately two-thirds of infants born very preterm received MOM at hospital discharge, and rates varied across NICUs. Supporting mothers to provide breast milk in the first 3 days after birth may be associated with improved MOM feeding rates at discharge.

ObjectiveTo predict preterm birth in nulliparous women using logistic regression and machine learning.DesignPopulation-based retrospective cohort.ParticipantsNulliparous women (N = 112,963) with a singleton gestation who gave birth between 20–42 weeks gestation in Ontario hospitals from April 1, 2012 to March 31, 2014.MethodsWe used data during the first and second trimesters to build logistic regression and machine learning models in a “training” sample to predict overall and spontaneous preterm birth. We assessed model performance using various measures of accuracy including sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (AUC) in an independent “validation” sample.ResultsDuring the first trimester, logistic regression identified 13 variables associated with preterm birth, of which the strongest predictors were diabetes (Type I: adjusted odds ratio (AOR): 4.21; 95% confidence interval (CI): 3.23–5.42; Type II: AOR: 2.68; 95% CI: 2.05–3.46) and abnormal pregnancy-associated plasma protein A concentration (AOR: 2.04; 95% CI: 1.80–2.30). During the first trimester, the maximum AUC was 60% (95% CI: 58–62%) with artificial neural networks in the validation sample. During the second trimester, 17 variables were significantly associated with preterm birth, among which complications during pregnancy had the highest AOR (13.03; 95% CI: 12.21–13.90). During the second trimester, the AUC increased to 65% (95% CI: 63–66%) with artificial neural networks in the validation sample. Including complications during the pregnancy yielded an AUC of 80% (95% CI: 79–81%) with artificial neural networks. All models yielded 94–97% negative predictive values for spontaneous PTB during the first and second trimesters.ConclusionAlthough artificial neural networks provided slightly higher AUC than logistic regression, prediction of preterm birth in the first trimester remained elusive. However, including data from the second trimester improved prediction to a moderate level by both logistic regression and machine learning approaches.

Pregnancy-induced hypertension (PIH) is associated with preterm delivery but its independent impact on neonatal outcomes remains unclear. We sought to systematically review and meta-analyze clinical outcomes of preterm infants37 weeks' gestation born to mothers with and without PIH.Medline, Embase, PsychINFO and CINAHL were searched from January 2000 to October 2016. Studies with low-moderate risk of bias reporting neonatal outcomes based on PIH as primary exposure variable were included. Data were extracted independently by two co-authors.PIH was associated with lower mortality (3 studies; adjusted odds ratio (aOR) 0.65; 95% confidence interval (CI) 0.54 to 0.79), lower severe retinopathy of prematurity (ROP) (2 studies; aOR 0.83; 0.72 to 0.96) and lower severe brain injury (2 studies; unadjusted OR (uOR) 0.57; 0.49 to 0.66). No association between PIH and short-term respiratory outcomes, bronchopulmonary dysplasia (BPD) or necrotizing enterocolitis (NEC) was identified. In subgroup analysis among infants29 weeks' gestation, BPD odds were higher (3 studies; aOR 1.15; 1.06 to 1.26), whereas mortality lower (2 studies; aOR 0.73; 0.69 to 0.77). In subgroup analysis limited to severe PIH, odds of mortality (3 studies; uOR 2.36; 1.07 to 5.22) and invasive ventilation (3 studies; uOR 3.26; 1.11 to 9.61) were higher. In subgroup analysis limited to preeclampsia, odds of BPD (3 studies; uOR 1.21; 95% CI:1.03 to 1.43) and NEC were higher (3 studies; uOR 2.79; 95% CI:1.57 to 4.96).PIH was associated with reduced odds of mortality and ROP (all infants), but higher odds for BPD (29 weeks' gestation). The paradoxical reduction in mortality may be due to survival bias and deserves further exploration in future studies.