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Objective At the Maternal Health Clinic (MHC), women with certain pregnancy complications are seen for appointments focusing on lifestyle modification and future pregnancy counselling. This study's objective is to determine whether women who attended the MHC following a pregnancy complicated by gestational diabetes mellitus (GDM) or a hypertensive disorder of pregnancy (HDP) have improved interpregnancy and subsequent pregnancy outcomes, compared with non-attendees. Methods A retrospective cohort study was conducted including all pregnancies ≥20 weeks gestation at Kingston Health Sciences Centre (KHSC) from April 2010 to Dec 2019. Women with ≥2 deliveries were eligible for inclusion, with 2 pregnancies per woman included. These criteria identified 178 patients who attended the MHC and 133 who did not. Continuous variables with normal distribution were assessed with independent sample t tests. Continuous variables without normal distribution and ordinal variables were assessed with Mann–Whitney U tests. Categorical variables were assessed with Pearson's χ2 tests. Preterm delivery, HDP and GDM recurrence, HDP and GDM progression, and change in first-trimester blood pressure and pre-pregnancy weight were examined using multivariate regression modelling. Probability values Results MHC attendance was associated with improvements in interpregnancy weight reduction (P = 0.002), fewer interpregnancy type II diabetes diagnoses (P Conclusion In our examination of MHC outcomes, we found improvements in certain interpregnancy and subsequent pregnancy outcomes. These results support the continued development and funding of these clinics.

OBJECTIVE Caesarean section (CS) is more common following infertility treatment (IT) but the reasons why remain unclear and confounded. The Robson 10-Group Classification System (TGCS) may further explain variation in CS rates. We assessed the association between mode of conception and CS across Robson groups. DESIGN Population-based cohort study. SETTING Ontario, Canada, in a public healthcare system. POPULATION 921 023 births, 2006-2014. METHODS Modified Poisson regression produced relative risks (RR) and 95% confidence intervals, comparing the risk of CS among women with (1) subfertility without IT, (2) non-invasive IT (OI, IUI) or (3) invasive IT (IVF)-each relative to (4) spontaneous conception (SC). MAIN OUTCOME MEASURES CS rate according to one of four modes of conception, overall and stratified by each of the TGCS groups. RESULTS Relative to SC (26.9%), the risk of CS increased in those with subfertility without IT (RR 1.17, 95% CI 1.16-1.18), non-invasive IT (RR 1.21, 95% CI 1.18-1.24) and invasive IT (RR 1.39, 95% CI 1.36-1.42). Within each Robson group, similar patterns of RRs were seen, but with markedly differing rates. For example, in Group 1 (nulliparous, singleton, cephalic at ≥37 weeks, with spontaneous labour), the respective rates were 15.0, 19.4, 18.7 and 21.9%; in Group 2 (nulliparous, singleton, cephalic at ≥37 weeks, without spontaneous labour), the rates were 35.9, 44.4, 43.2 and 54.1%; and in Group 8 (multiple pregnancy), they were 55.9, 67.5, 65.0 and 69.3%, respectively. CONCLUSIONS CS is relatively more common in women with subfertility and those receiving IT, an effect that persists across Robson groups. TWEETABLE ABSTRACT Caesarean delivery is more common in women with infertility independent of demographics and prenatal conditions.

The majority of women do not meet the recommended levels of exercise during their pregnancies, frequently due to a lack of time. High-intensity interval training offers a potential solution, providing an effective, time-efficient exercise modality. This exercise modality has not been studied in pregnancy therefore, the objective of this study was to evaluate fetal response to a high-intensity interval training resistance circuit in the late second and early third trimesters of pregnancy. Fourteen active, healthy women with uncomplicated, singleton pregnancies participated in a high-intensity interval training resistance circuit between 28 + 0/7 and 32 + 0/7 weeks. A Borg rating of perceived exertion of 15–17/20 and an estimated heart rate of 80%–90% of maternal heart-rate maximum was targeted. Fetal well-being was evaluated continuously with fetal heart-rate tracings and umbilical artery Doppler velocimetry conducted pre-and post-exercise. Fetal heart rate tracings were normal throughout the exercise circuit. Post-exercise, umbilical artery end-diastolic flow was normal and significant decreases were observed in the mean systolic/diastolic ratios, pulsatility indexes and resistance indexes. Therefore, in a small cohort of active pregnant women, a high-intensity interval training resistance circuit in the late second and early third trimesters of pregnancy appears to be a safe exercise modality with no acute, adverse fetal effects but further study is required. Novelty: High-intensity interval training, at an intensity in excess of current recommendations, does not appear to be associated with any adverse fetal effects in previously active pregnant women. High-intensity interval training is an enjoyable and effective exercise modality in previously active pregnant women.

This study compared pregnancy-related cardiovascular disease risk indicators between women who attended 2 different postpartum screening and education clinics: 1 at an urban tertiary care centre and 1 at a northern, rural community hospital. Risk differences associated with ethnicity were also examined.We conducted a retrospective record review that compared data from an urban clinic in Kingston, Ontario (n = 675) with those from a rural clinic in Prince Rupert, British Columbia (n = 65). Patients who had a hypertensive disorder of pregnancy, gestational diabetes, intrauterine growth restriction, idiopathic preterm birth, or placental abruption attended the clinics at 6 months postpartum. Demographic information, personal and family history, physical examination findings, and laboratory results were collected and used to generate cardiovascular risk estimates using validated scoring systems. These estimates were compared between clinic populations and between ethnic subsets.Fifty-five percent of the Prince Rupert cohort were Indigenous, while 87% of the Kingston cohort were White (P0.001). A greater proportion of the Kingston cohort had experienced hypertensive disorders of pregnancy (P = 0.002), while a greater proportion of the Prince Rupert cohort had developed gestational diabetes (P=0.010). The Prince Rupert population had higher lifetime and 30-year cardiovascular disease risk scores (P = 0.008 and P = 0.005, respectively). Indigenous patients had more major cardiovascular risk factors as well as higher lifetime and 30-year cardiovascular risk scores (P = 0.001 and P = 0.008, respectively) than White and Asian patients.The increased cardiovascular disease risk in both rural and Indigenous women supports the need for better postpartum care, long-term follow-up, and early promotion of cardiovascular health in these populations.

Our study assessed the rate of new and recurrent Chlamydia trachomatis and Neisseria gonorrhoeae infections in the third trimester at an adolescent obstetrics clinic.Between October 2016 and June 2020, routine third-trimester screening for C. trachomatis and N. gonorrhoeae was implemented according to new Canadian recommendations. Urine nucleic acid amplification was performed. Patient records were reviewed retrospectively, and demographic data; pregnancy and delivery characteristics; and information on screening at presentation to care, third-trimester screening (33-38 weeks), and other STI testing was recorded.A total of 115 adolescents (mean age 17.90 ± 1.43 y) with 125 pregnancies presented for care. Twenty-three pregnancies were excluded (12 transferred out and 11 experienced a pregnancy loss). At presentation, screening was performed in 100 of 102 pregnancies: 64 of 100 at13 weeks, 32 of 100 at 13-27 weeks, and 4 of 100 at 28-30 weeks. Nine tested positive for C. trachomatis and none tested positive for N. gonorrhoeae. In the third trimester, there were 3 positive C. trachomatis tests, but all were indicated: test of cure was due for 1 patient, 1 patient had a new sexual partner, and 1 patient presented with symptoms. The remaining 89 of 102 pregnancies were screened (with no other indication) and none were positive for C. trachomatis or N. gonorrhoeae. Ten patients could not be sampled (5 missed, 4 pre-term deliveries, and 1 non-compliant with testing).No cases of C. trachomatis or N. gonorrhoeae infection were identified on third-trimester screening in our study. Adolescent obstetrics providers implementing Canadian screening guidelines may want to monitor their screening results to determine whether their yield warrants universal implementation.

While survival after hematological malignancies in adolescent and young adult patients is improving, patients report poor oncofertility care. This population-based, retrospective, cohort study used data from the Ontario Cancer Registry and billing codes to identify fertility consultations for lymphoma patients between 2000 and 2018. Consultation trends across time and different patient and physician characteristics were analyzed. We identified 2088 patients and a consultation rate of 3.4% (increasing from 1% in 2000-2006 to 8% in 2014-2018). Patient parity and regional deprivation scores decreased rates. Despite mild improvement, there is ample missed opportunity for fertility discussions.

We examine maternal microvascular function after preeclampsia, identifying heightened endothelium-dependent and endothelium-independent microvascular reactivity following severe disease. Our study represents a noteworthy addition to the existing literature with the use of a novel imaging modality, vascular perturbation, postpartum time point, and patient population with differentiation of preeclampsia into severe and nonsevere subtypes. These results represent a novel addition to the growing clinical and academic understanding of maternal health outcomes following preeclampsia.

Objective To compare the efficacy of two methods of outpatient cervical ripening (CR): an intracervical Foley catheter and a prostaglandin E2 (PGE)2 slow-release vaginal insert. Methods All records of women receiving outpatient CR at a tertiary care hospital from January 2017 to June 2018 were retrospectively reviewed. We compared time from insertion of first CR agent until delivery between groups using a Cox proportional hazards (CPH) model. Exclusion criteria included age Results A total of 153 patients were included (82 Foley; 71 PGE2). Baseline characteristics were comparable except for lower dilation in the PGE2 group (16% vs. 38% Conclusion Our results suggest that outpatient Foley catheter and PGE2 CR are comparable in time from insertion to delivery; however, PGE2 inserts are associated with higher rates of tachysystole and the need for second CR method. A prospective study is warranted to further investigate these findings.

Objective Pelvic organ prolapse (POP) surgery may unmask occult stress urinary incontinence (OSUI) in otherwise asymptomatic patients. Preoperative urodynamic studies (UDSs) with prolapse reduction may, by potentially unmasking OSUI, assist surgical decision making. This study investigated the long-term objective postoperative rate of SUI, according to the presence of OSUI. Methods This retrospective cohort study was conducted with a cross-sectional survey of women with no SUI or rare SUI presenting at Kingston General Hospital in Kingston, Ontario from 2003-2013 for POP. Patients were compared on the basis of preoperative UDS results and whether an anti-incontinence procedure was performed in addition to POP surgery. The study included a chart review of 1-year follow-up subjective results and a survey of long-term objective results (symptoms and quality of life) ascertained by validated questionnaires. Results The study enrolled 113 women, 51 of whom had undergone anti-incontinence surgery (42 for identified OSUI, 9 prophylactically). In women whose UDS results indicated OSUI, 1-year subjective and long-term objective postoperative SUI results were, respectively, 8.8% and 12.5% among women undergoing POP and anti-incontinence surgery and 18.2% and 42.9% among those undergoing POP surgery alone. In women with negative UDS results, those rates were 0.0% and 50.0% and 12.8% and 27.6%, respectively. There was no significant difference in any outcomes, according to procedure choice in the OSUI-positive group. There were no predictors for postoperative SUI. Conclusion Although a trend was seen for less long-term validated subjective SUI in women having a concomitant SUI procedure along with POP corrective surgery, no significant difference in outcomes was found, on the basis of procedure of choice, and no reliable predictors for postoperative SUI could be identified. UDS testing may be useful to rule in OSUI, but its clinical value in surgical decision making is uncertain.

Purpose To determine whether age modifies the effect of the number of motile spermatozoa inseminated (NMSI) as a predictor of success in Intrauterine Insemination (IUI). Methods This retrospective cohort study included all patients who underwent IUI at an academic infertility center between October 2004 and June 2018. The primary outcome was clinical pregnancy (CP; a gestational sac and fetal heartbeat on ultrasound). Results were analyzed by patient factors including age, NMSI, duration of infertility, and cause of infertility, along with treatment factors such as number of follicles and ovulation induction protocol. Factors associated with the odds of achieving a clinical pregnancy were analyzed using binary logistic generalized estimating equations to control for clustering effects by couple. Female age was categorized as

The purpose of this study was to determine the prevalence, impact and management of stress urinary incontinence (SUI) among rope-skipping (RS) athletes. A cross-sectional observational study was employed. Survey #1 (current athletes): RS athletes aged ≥13 years attending a national RS competition (183) were invited to participate. The primary outcome was the prevalence of SUI during RS (yes/no question). Secondary outcomes included SUI interference with RS (Likert scale, 0–10), quality of life (ICIQ-SF), and the prevalence and bothersomeness of SUI for each RS event (un-validated sport-specific questionnaire inspired by the IIQ-7). Survey #2 (retired athletes): retired RS athletes were invited to complete an online questionnaire to identify whether SUI contributed to their retirement from RS. Survey #1: 56% (103 out of 183) of athletes responded. Athletes were predominantly girls of adolescent age, normal weight, menarchal, and nulliparous. Seventy-five percent of the girls (67 out of 89) and 7% of boys (1 out of 14) reported SUI during RS, mostly when competing “double-unders” and “triple-unders.” Twenty-one percent (14 out of 67) of affected girls indicated a moderate or greater interference of SUI with RS, although the median impact of SUI on their overall quality of life was slight. Female athletes managed SUI with containment products, fluid limitation, and timed voiding. Survey #2: one of the 77 respondents (74 females, 3 males) indicated that SUI contributed to their retirement from RS. Similar to other high-impact sports, female RS athletes experience a relatively high rate of SUI while participating in RS, which may lead to decreased quality of life.

This study sought to identify knowledge gaps and attitudinal barriers to prescribing intrauterine contraception (IUC).A national, Web-based survey of Canadian gynaecology (GYN) and family medicine (FM) physicians was conducted. The survey was distributed through several channels, including physicians' databases, invitations through a commercial email aggregating service, and contacting residency programs. For knowledge-based questions, correct answers were those consistent with Canadian practice guidelines. Ethics approval was granted through Queen's Health Sciences Research Ethics Board. Project funding was through a research grant from Bayer, Inc. (Canadian Task Force Classification III).A total of 600 responses were received. GYN physicians' knowledge about IUC (number correct / 40) was better than that of the FM and FM with additional women's health training (FMWH) groups (median [interquartile range] 39 [37-40], 36 [32-38], and 37 [35-39]; P 0.0001). Factors associated with lower scores included rural practice location, lack of affiliation with medical trainees, extremes of practice duration, and self-perceived lack of knowledge about IUC. Most respondents prescribed IUC (93.7%). Among prescribers, 97.0% inserted IUC. The most common reasons for not prescribing or inserting IUC included lack of training, lack of comfort, and referral to other physicians to provide this service. Respondents indicated that they would be more likely to prescribe and/or insert IUC if cost barriers were removed, patient interest was increased, or if there was improved access to patient-centred educational materials and hands-on training modules.This study suggests that although many GYN and FM physicians are offering IUC, misconceptions regarding contraindications still exist, and several barriers are related to deficiencies in providers' knowledge. Therefore, educational efforts should be prioritized to increase the usage of IUC.

Studies show poor maternal and fetal outcomes associated with prenatal cannabis use. With the legalization of cannabis in Canada, it is of timely importance to increase awareness of the effects of its use in pregnancy. An anonymous, online questionnaire was used to assess the pregnant population's knowledge, beliefs, and risk perceptions concerning cannabis. Additionally, educational materials on the effects of prenatal cannabis use were evaluated. A potential knowledge gap was found among 9%-19% of participants, who reported that cannabis posed no risk of harm to the pregnant person or fetus. Moreover, minor changes could improve the effectiveness of educational resources.

Objectives To evaluate surgeon opioid prescribing patterns for patients undergoing hysterectomy for benign indication, as well as patient use of postoperative medications and satisfaction with postoperative pain management. Methods Patients undergoing hysterectomy for benign indications at [redacted] were invited to participate in a telephone survey 2 weeks post-surgery to review their analgesia use and pain management. Patient demographics, medical history, intraoperative surgical details, and postoperative prescriptions were gathered through patient record review. Opioid prescribing and utilization patterns were assessed, as was satisfaction with postoperative pain management. Results Of 124 eligible patients 110 (89%) completed the telephone survey, a mean 15.9 ± 2.3 days after surgery. The mean age of participants was 51.6 ± 11.9 years. Most surgeries (84.5%) were minimally invasive, and 45.5% of patients were discharged within 24 hours of surgery. An opioid prescription was given to 71.8% of participants, and 52.7% used at least 1 dose of opioid medication after discharge. Most participants described very good or adequate postoperative pain management (88.2%). Satisfaction with postoperative pain control was not associated with receipt of an opioid prescription (P = 0.89). A greater proportion of those who used 1 or more doses of opioids versus none indicated poor or inadequate pain management (19.0% vs. 4.1%; P = 0.035). Conclusion Many patients do not use postoperative opioid analgesia following hospital discharge after hysterectomy, without experiencing poor pain management. Surgeons should assess each individual and tailor the analgesia plan as necessary, optimizing non-opioid options.

INTRODUCTION Our objective was to compare the short-term outcomes by type of surgical management of endometriosis in Ontario, Canada and to characterize the population of women undergoing surgical management of endometriosis. MATERIAL AND METHODS We conducted a population-based cohort study including women aged 18-50 years undergoing same-day or inpatient surgery for endometriosis from 1 April 2002 through 31 March 2018. Surgery was classified as minimally invasive hysterectomy (MIH), total abdominal hysterectomy (TAH) or minor or major conservative (uterus-preserving) surgery. Outcomes examined included length of stay, intraoperative complications, postoperative complications, emergency department visits, ambulatory care visits, and readmission. We estimated the relative risk of these outcomes in minor, major conservative surgery and TAH vs MIH adjusted for age, income quintile, parity, and comorbidities. RESULTS A total of 85 605 patients underwent surgery, 12.9% MIH, 22.1% TAH, 36.3% major conservative, and 28.6% minor conservative. The mean age at index surgery was 37.6 ± 7.7 years. Before surgery, 70.6% of patients had visited a physician for pain at least once (64.7% MIH, 69.5% TAH, 71.1% major conservative and 73.4% minor conservative) and 23.5% of patients had sought infertility consultation (5.7% MIH, 6.6% TAH, 29.3% major conservative and 37.1% minor conservative). The overall risk of intraoperative and postoperative complications was 1.5% and 4.7%, respectively. In adjusted models, compared with those undergoing minor conservative surgery, those having major conservative surgery were 1.77 (95% CI 1.49-2.11) times as likely to experience an intraoperative complication, those having MIH and TAH were 2.55 (95% CI 2.08-3.13) and 2.34 (95% CI 1.93-2.82) times as likely to do so, respectively. Similarly, compared with those undergoing minor conservative surgery, those having major conservative surgery were 2.60 (95% CI 2.30, 2.93) times as likely to experience any postoperative complication, and those having MIH and TAH were 4.69 (95% CI 4.11-5.36) and 5.38 (95% CI 4.76-6.09) times as likely to do so, respectively. CONCLUSIONS Approximately one-third of patients undergoing surgical management for endometriosis in Ontario between 2002 and 2018 had a hysterectomy. Overall, complications following surgery were low, and dependent on extent of surgery. These results should help to inform preoperative counseling for patients and health policy development for providers.

BackgroundCaesarean section rates are higher among pregnancies conceived by assisted reproductive technology (ART) compared to spontaneous conceptions (SC), implying an increase in neonatal and maternal morbidity. We aimed to compare caesarean section rates in ART pregnancies versus SC, overall, by indication (elective versus emergent), and by type of ART treatment (in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), fresh embryo transfer, frozen embryo transfer) in a systematic review and meta-analysis.MethodsWe searched Medline, EMBASE and CINAHL databases using the OVID Platform from 1993 to 2019, and the search was completed in January 2020. The eligibility criteria were cohort studies with singleton conceptions after in-vitro fertilization and/or intracytoplasmic sperm injection using autologous oocytes versus spontaneous conceptions. The study quality was assessed using the Newcastle Ottawa Scale and GRADE approach. Meta-analyses were performed using odds ratios (OR) with a 95% confidence interval (CI) using random effect models in RevMan 5.3, and I-squared (I2) test > 75% was considered as high heterogeneity.ResultsOne thousand seven hundred fifty studies were identified from the search of which 34 met the inclusion criteria. Compared to spontaneous conceptions, IVF/ICSI pregnancies were associated with a 1.90-fold increase of odds of caesarean section (95% CI 1.76, 2.06). When stratified by indication, IVF/ICSI pregnancies were associated with a 1.91-fold increase of odds of elective caesarean section (95% CI 1.37, 2.67) and 1.38-fold increase of odds of emergent caesarean section (95% CI 1.09, 1.75). The heterogeneity of the studies was high and the GRADE assessment moderate to low, which can be explained by the observational design of the included studies.ConclusionsThe odds of delivering by caesarean section are greater for ART singleton pregnancies compared to spontaneous conceptions. Preconception and pregnancy care plans should focus on minimizing the risks that may lead to emergency caesarean sections and finding strategies to understand and decrease the rate of elective caesarean sections.

Background Cigarette smokers have a reduced risk of developing preeclampsia, possibly attributed to an increase in carbon monoxide (CO) levels. Carbon monoxide is a gasotransmitter that has been implicated in maintaining vascular tone, increasing angiogenesis, and reducing inflammation and apoptosis at physiological concentrations. Moderately increasing CO concentrations may have therapeutic potential to prevent or treat preeclampsia; however, the effects of CO on pregnancy are under studied. Our objective was to investigate the effect of CO on major angiogenic and inflammatory markers in pregnancy, and to evaluate the effect of CO on indicators of placental health. Findings Pregnant CD-1 mice were constantly exposed to either ambient air or 250 ppm CO from conception until gestation day (GD)10.5 or GD16.5. Using a qRT-PCR array, we identified that CO increased expression of major angiogenic genes at the implantation site on GD10.5, but not GD16.5. Pro-inflammatory cytokines in the plasma and tissue lysates from implantation sites in treated mice were not significantly different compared to controls. Additionally, CO did not alter the implantation site phenotype, in terms of proliferative capacity, invasiveness of trophoblasts, or abundance of uterine natural killer cells. Conclusions This study suggests that CO exposure is pro-angiogenic at the maternal-fetal interface, and is not associated with demonstrable concerns during murine pregnancy. Future studies are required to validate safety and efficacy of CO as a potential therapeutic for vascular insufficiency diseases such as preeclampsia and intrauterine growth restriction.

Purpose The use of assisted reproductive technology (ART) has increased in the last 2 decades and continuous surveillance is needed. This systematic review aims to assess the risk of adverse neonatal outcomes (preterm birth [PTB], low birth weight [LBW], small-for-gestationalage [SGA] and large for gestational-age [LGA]), in singleton pregnancies conceived by fresh or frozen embryo transfer (FET) compared to spontaneous conceptions. Methods Cohort studies were identified from MEDLINE, Embase, Cochrane Library (January 2019), and manual search. Meta-analyses were performed to estimate odds ratios (OR) using random effects models in RevMan 5.3 and I-squared (I2) test > 50% was considered as high heterogeneity. Results After 3142 titles and abstracts were screened, 1180 full-text articles were assessed, and 14 were eligible. For fresh embryo transfer, the pooled ORs were PTB 1.64 (95% CI 1.46, 1.84); I2 = 97%; LBW 1.67 (95% CI 1.52, 1.85); I2 = 94%; SGA 1.46 [95% CI 1.11, 1.92]; I2 = 99%, LGA 0.88 (95% CI 0.80, 0.87); I2 = 80%). For frozen, the pooled ORs were PTB 1.39 (95% CI 1.34, 1.44); I2 = 0%; LBW 1.38 (95% CI 0.91, 2.09); I2 = 98%; SGA 0.83 (95% CI 0.57, 1.19); I2 = 0%, LGA 1.57 (95% CI 1.48, 1.68); I2 = 22%). Conclusions When compared with spontaneous pregnancies, fresh, but not frozen was associated with LBW and SGA. Both fresh and frozen were associated with PTB. Frozen was uniquely associated with LGA. Despite improvements in ART protocols in relation to pregnancy rates, attention is needed towards monitoring adverse neonatal outcomes in these pregnancies.

Objective To determine the association of preeclampsia (PE) with the presence of cardiovascular risk (CVR) factors at approximately 11 years postpartum and to assess the longer term effect of PE on childhood development. Study Design A mail-out survey was sent to all women who were previously recruited into the Kingston arm of the Pre-Eclampsia New Emerging Team's prospective cohort (n = 112 PE and n = 150 control). Physical and biochemical CVR markers were compared between the two groups. Physical, social, and cognitive development of the children involved in the pregnancies was evaluated using the Vineland-3 Domain-Level Parent/Caregiver Form. Results Thirteen PE women and 28 control women returned the study questionnaire. Based on the 2017 American Heart Association High Blood Pressure Clinical Practice Guidelines, 9/13 (69.2%) of the PE women, compared with 6/28 (21.4%) of the control women, have hypertension (p Conclusion The development of PE leads to longer term changes in CVR markers and in childhood development at approximately 11 years postpartum. Pregnancy and the postpartum provide an early window of opportunity for early maternal and child screening and intervention for health preservation and disease prevention.

OBJECTIVES To determine whether delay of initial anatomy ultrasound based on the maternal body mass index (BMI) reduces the rate of inadequate visualization compared to standard timing at 180/7 to 196/7 weeks. METHODS A retrospective study of singleton anatomy assessments was conducted at a tertiary care center in the 2-year period before (A, 2012-2014) and after (B, 2014-2016) protocol initiation. Assessments in period B were scheduled on the basis of the BMI in the first trimester: lower than 25 kg/m2 , 180/7 to 196/7 weeks; 25 to 29.9 kg/m2 , 190/7 to 206/7 weeks; 30 to 34.9 kg/m2 , 200/7 to 216/7 weeks; 35 to 39.9 kg/m2 , 210/7 to 226/7 weeks; and 40 kg/m2 or higher, 220/7 to 236/7 weeks. In period A, assessments were scheduled between 180/7 and 196/7 weeks. The rate of inadequate visualization and repeated assessments in periods A and B were compared. Multivariable logistic regression, per-protocol, and BMI subgroup analyses were completed. RESULTS In total, 3491 pregnancies in period A and 3672 in period B were included. In period B, 74% were scheduled per protocol; however, this rate decreased for higher-BMI categories (52% for BMI ≥40 kg/m2 ). The inadequate visualization rate was slightly higher in period B versus A (16.9% versus 15.0%; P = .03) and exceeded 35% for a BMI of 40 kg/m2 or higher, with or without delay. After adjusting for maternal age and fetal presentation, period B had small increased odds of inadequate visualization versus period A (adjusted odds ratio, 1.2; 95% confidence interval, 1.02-1.38). Repeated assessment rates were similar in periods B and A (14.0% versus 13.1%; P = .25). CONCLUSIONS In pregnancies with obesity, a protocol delaying the initial assessment beyond 196/7 weeks based on the maternal BMI does not reduce the rate of inadequate visualization.

Objectives To investigate the short-term effects of breastfeeding on hypertension, metabolic syndrome, serum glucose and cholesterol profile among postpartum women 6 months after a pregnancy complicated by hypertensive disorders of pregnancy, gestational diabetes, intrauterine growth restriction, abruption, and preterm delivery. Methods Our cross-sectional analysis includes 622 women with a pregnancy complication seen at 6 months postpartum between November 2011 and December 2017 at a tertiary care centre. We compared systolic and diastolic blood pressure, serum cholesterol profile, serum glucose, and estimated cardiovascular risk in women who did not breastfeed (n=100, 16%), who breastfed for less than 6months (n=315, 51%), and who breastfed for 6 months or more (n=207, 33%) using descriptive statistics and multivariate linear and logistic regression. Results Adjusted models showed that increasing breastfeeding duration significantly decreased the odds of metabolic syndrome (Odds Ratio [95% Confidence Interval]; 0.88 [0.80, 0.98]), a high lifetime risk score (0.92 [0.80, 0.99]), elevated (0.92 [0.84, 0.99]) or hypertensive systolic blood pressure (0.90 [0.82, 0.99]), abnormal fasting glucose (0.80 [0.67, 0.95]), triglycerides (0.88 [0.79, 0.97]), and ratio of total cholesterol to HDL-C (0.86 [0.79, 0.94]). BMI, waist circumference and non-HDL-C decreased (estimated coefficients [95%CI]; of -0.11 [-0.19, -0.03], -0.32 [-0.60, -0.04], -0.04 [-0.88, -0.07]; respectively) while HDL-C increased (0.03 [-0.02, -0.04]). Conclusions Our findings suggest that breastfeeding for at least 6 months is associated with decreased indicators of cardiovascular disease risk in a cohort of women with a recent pregnancy complication and should encourage breastfeeding support and interventions in this population.

Pre-eclampsia is associated with an increased risk of future cardiovascular disease. Maladaptive placentation or malperfusion, as well as predisposing cardiovascular or metabolic risk for endothelial dysfunction, contribute to the systemic inflammatory response that establishes the origins of the disease. The purpose of this study was to investigate the relationship between placental size and cardiovascular risk when assessed at six months postpartum in women who experienced pre-eclampsia.Maternal clinical and biochemical cardiovascular risk factors were used to categorize preeclamptic women into high vs. low lifetime cardiovascular disease risk profiles at six months postpartum. A multivariable logistic regression model was then used to identify the association between placental weight to birth weight ratio and high lifetime cardiovascular disease risk, adjusting for maternal age, pre-pregnancy BMI, and severity of pre-eclampsia. A p-value of 0.05 was deemed statistically significant.186/216 women with pre-eclampsia who attended the Maternal Health Clinic met inclusion criteria. No significant differences were observed for placental morphometric measurements between women who screened as having a high vs. low lifetime risk profile for cardiovascular disease at six months postpartum. However, using multivariable modelling that controlled for maternal age, pre-pregnancy body mass index, gestational age at delivery, and severity of pre-eclampsia, a low placenta to birth weight ratio (15%) was associated with an increased odds of high lifetime cardiovascular disease risk (p 0.009).The findings of the current study identify clinical measurements that can be collected at the time of delivery which may help identify specific women who may benefit most from postpartum cardiovascular risk screening and intervention.

Objectives To compare the distribution of uric acid (UA) concentration in women with normal and preeclamptic pregnancy, to investigate the significance of UA concentration in diagnosis of preeclampsia, and to estimate the UA rate of change over time before delivery. Study design A case-control study of singleton pregnancies was completed at a tertiary care center in Kingston, Ontario. Patients with preeclampsia were recruited through two prospective cohort studies (n = 218); the Preeclampsia New Emerging Team (September 2003–October 2009) and the Maternal Health Clinic (May 2011–June 2016). Individuals who had an uncomplicated pregnancy and delivered (July 2016–August 2017), were included in the control arm (n = 73). Main outcome measures Longitudinal analysis using a linear mixed-effects model examined the UA rate of change over time. The distribution of the UA level was compared using a t-test. The significance of the UA level in the diagnosis of preeclampsia was examined using multiple logistic regression. Results The rate of change in UA before delivery had an increasing non-constant logarithmic trend with time. Mean UA level in preeclamptic pregnancies (369.53 ± 75.78 μmol/l) was significantly elevated compared with the normal pregnancies (292.55 ± 54.73 μmol/l). UA had an adjusted odds ratio of 1.39 (95%CI: 1.14–1.69; P = 0.001) associated with the incidence of preeclampsia and UA level >349 μmol/l close to delivery is an accurate measurement for diagnosing preeclampsia. Conclusion The UA concentration in preeclamptic pregnancies is significantly increased compared to normal pregnancies and the level of UA may have diagnostic ability in the occurrence of preeclampsia.

Objectives Caesarean section rates (CSR) are higher in infertility treatment (IT) pregnancies compared to spontaneous conceptions (SC). We assess the association between mode of conception and CSR in Ontario using the Robson Classification. Methods We conducted a population-based cohort study of deliveries from 2006-2014. Exposures were SC; subfertility (infertility consult without IT); non-invasive IT (OI, IUI); and invasive IT (IVF, ICSI). Deliveries were classified into Robson groups based on parity, previous caesarean section (CS), gestational age, onset of labour, fetal presentation, and number of fetuses. CSR were calculated overall and by Robson group. Modified risk ratios (RR) were reported for the association between exposure and CSR. Results In 921,023 deliveries, CSR were 26.9% with SC, 36.3% with subfertility, 38.8% with non-invasive IT, and 50.6% with invasive IT. Compared to SC, the risk of CS rose by IT invasiveness; with a RR of 1.38 (95% CI 1.36-1.42) in invasive IT. In non-invasive IT, Group 2 (nulliparous, singleton, cephalic, > 36 weeks) and Group 8 (multiple pregnancy) made the largest contribution to CSR at 22.5% and 19.8%. In invasive IT, Group 8 made the largest contribution to CSR at 34.9%. Compared to SC, Robson Groups 3 or 4 (multiparous, singleton, cephalic, > 36 weeks, without a previous CS) with invasive IT had the highest risk of a CS. Conclusions Multiple pregnancy contributes the most to CSR in women with IT. The increased risk of CS in multiparous women with subfertility or IT with no history of a previous CS should be studied.

Objectives Our tertiary-care centre began offering water immersion (WI) in 2018. This project aims to assess the safety of WI and guideline implementation. Methods A retrospective chart-review of patients who used WI from January 2018 to March 2020 was conducted. The study groups were WI use, WI deliveries, and WI eligible patients. Exclusion criteria for the WI eligible group was multiple gestation, planned C-section, breech presentation, intrauterine fetal demise, pregnancy loss, preterm labour, home birth, infection, or weight greater than 136.1 kg. Maternal and fetal outcomes including labour length, blood loss, and NICU admission were noted. Chi square and Kruskal-Wallis tests were used for analysis. Results Of the 4013 births during the study period, 2719 were eligible for WI but did not use it, 132 used WI, and 48 delivered during WI. Midwives oversaw most WI deliveries (93.8%). Three patients used WI despite exceeding weight restrictions. Other guidelines were followed. In the WI eligible and WI use groups 13.3% and 7.6% delivered by C-section, respectively (p=0.06). For vaginal deliveries, the WI delivery group had shorter 2nd stage (median=15, IQR=8.3-32mins) than the WI eligible (median=40, IQR=15-102mins) and WI use groups (median=42, IQR=20.8-108mins; p Conclusions Patients who use WI had acceptable safety outcomes. Adherence to maternal weight guidelines could be improved.

Objectives To assess the risk of premature ovarian Insufficiency (POI) in female adolescent and young adult (AYA) survivors of non-gynecologic cancers, using a population-based approach. Methods Provincial healthcare databases were used to identify women 15-39 years old diagnosed with selected cancers (breast, hematological, thyroid, and melanoma) from 1995-2015. Those who lived ≥3 years after diagnosis were included (n=21,666). Each cancer survivor was matched by birth year and census subdivision to 5 randomly selected cancer-free women (n=108,330). Women with bilateral oophorectomy or previous menopause were excluded. Participants were followed until December 2018, bilateral oophorectomy, loss of health insurance or death. POI was identified through physician billing claims coded as a diagnosis of menopause before age 40 (ICD-9 code 627). Modified Poisson regression models were used to calculate the adjusted relative risk (aRR) of POI for AYA cancer survivors, adjusted for income, parity, and immigration status. Results The mean age at cancer diagnosis was 32.12 years (SD 5.59). There was a higher frequency (5.4% vs. 2.2%) and increasedrisk (aRR 2.47, 95% CI 2.30–2.65) of POI amongst the AYA cancer survivors in comparison to controls. Risk varied by type of cancer: breast (4.37; 3.88–4.93), non-Hodgkin's lymphoma (3.72; 2.87–4.83), Hodgkin's lymphoma (2.38; 1.92–2.96), leukemia (14.01; 10.16–19.32), thyroid (1.25; 1.08–1.44) and melanoma (1.05; 0.83–1.33). Conclusions This study identifies significant increased risk of POI in female AYA cancer survivors. Female AYAs with cancer should be counselled about, tested for, and when confirmed, treated for POI.

Objectives Endometriosis in adolescents is under-recognized and understudied, leading to delayed diagnosis and reduced quality of life. We aimed to appreciate the diagnostic and therapeutic journey of adolescents with endometriosis, including disease presentation, obstacles to diagnosis and management, and the impact of this condition on their life. Methods Women under twenty-eight years with severe dysmenorrhea were included. Participants were identified through a retrospective review of gynaecology rosters at a tertiary hospital and invited to complete a questionnaire assembled from the World Endometriosis Research Foundation and the SF36 questionnaire. A mixed study design was utilized. Participants were further invited to complete a semi-structured phone interview. Questionnaire data was analyzed using descriptive statistics. Interviews were coded using the constant comparative analysis method by two analyzers and inter-rater reliability was calculated. Thereafter, both sets of data were compared using a cross-sectional method. Results Participants reported initial pelvic pain at a mean age of 13.9 years (SD 1.9). 50% of participants have an endometriosisdiagnosis, at a mean age of 19.2 years (SD 2.6). Mean dysmenorrhea pain score was 8.3 (SD 1.8) on a 10-point severity scale. 90% reported severe pain requiring bed rest and medication. When experiencing pelvic pain, nine participants reported dyspareunia. The highlight of our project will likely be the unique and in-depth interview insights into the journey of adolescents with endometriosis. Conclusions Adolescents with endometriosis encounter multiple obstacles. From initial analysis, symptoms start young and are severe, quality of life is reduced, and there is a delay in diagnosis.

Objectives This study compared pregnancy-related cardiovascular disease (CVD) risk indicators among women who attended two postpartum screening and education clinics: one in a tertiary care centre and one in a northern rural community. The differences in cardiovascular risk between Indigenous and non-Indigenous Canadian women were also examined. Methods We compared data from an urban, tertiary level clinic (N=675) with that from a northern rural clinic (N=65). Patients who developed hypertensive disorders of pregnancy, gestational diabetes, intrauterine growth restriction, idiopathic preterm birth or placental abruption attended at six months postpartum. Demographic information, personal and family history, physical examination findings, and laboratory results were collected and used to generate CVD risk estimates using validated scoring systems. These were compared between clinic populations and between ethnic subsets. Results 55% of the rural cohort were Indigenous, while 87% of the urban cohort were Caucasian (P Conclusions The increased cardiovascular risk in both rural and Indigenous patients supports the needs for the implementation of better postpartum care, long term follow-up and early promotion of cardiovascular health in these populations.

Objectives Our purpose is to provide expectations for health care practitioners who consider opening a transgender health practice. The primary objectives are to outline the referral pattern to, and services provided by, Kingston Transgender Clinic (KTC). The secondary objective is to assess quality indicators including rates of cervical screening and offers of fertility preservation. Methods A retrospective chart review by two abstractors was conducted spanning the 22 months since clinic initiation. Results 107 patients met inclusion criteria. Median age at referral was 20 years old. 17.48% of patients were under 16 years old. The majority of referrals were from family physicians and were for hormone therapy. Many patients sought top surgery (46.7%). 42.4% of patients required referral beyond KTC, mostly for mastectomy. The number of referrals steadily increased from clinic inception, and was associated with an increase in wait time from 58 days to 264 days one year later. Follow-up was ongoing for 90.2% of patients at the conclusion of the study. Cervical cancer screening was documented as up to date for 84.1% of eligible people. 66.2% of eligible patients had documented fertility preservation offers. Conclusions In the first two years of KTC, referral rates and wait times increased impressively, affirming the need for this clinic. Most patients required hormone therapy, which can be provided by a wide range of providers. Transgender Kingstonians previously had to travel hundreds of kilometres for care. At KTC, they now have most health needs met locally. This standard could be met in many parts of Canada by motivated health advocates.

Cardiovascular disease (CVD) is the leading cause of death globally among women, and certain pregnancy complications can be the earliest indicators of increased CVD risk. Nonetheless, there is no recommendation for follow-up of cardiovascular risk factors identified through postpartum screening programs. This study describes current referral practices and clinical course from the Maternal Health Clinic in Kingston, Ontario, for women deemed at high cardiovascular risk postpartum.We investigated the cohort of women referred from the postpartum Maternal Health Clinic to cardiology for further assessment and management, specifically examining timing and recommended interventions to reduce CVD risk.Women referred to cardiology differed significantly from those not referred in history of hypertensive disorders of pregnancy (P 0.05) and demonstrated a significantly worse CVD risk profile at 6 months postpartum (P0.0001). Life expectancy by the cardiometabolic model for women referred was 5 years shorter (P 0.0001). Only half of the women referred to cardiology scheduled a visit; the median time to the scheduled appointment was 12 months. Of women seen by cardiology, 60% were deemed eligible for cardiac rehabilitation.Although women at highest risk for CVD are being identified and referred to cardiology, the existing system is not designed for this demographic. Too many women are missing their appointments or being seen beyond 1 year postpartum. To initiate lifestyle changes and/or therapeutic interventions, we suggest that CVD prevention programming begins within 1 year of delivery. Future studies should investigate the viability of traditional cardiac rehabilitation programs among this unique population.

Preeclampsia (PE) is characterized by systemic maternal endothelial dysfunction. Changes in endothelial reactivity have been reported before the onset of clinical signs of PE, and continuing into the post-partum period. Women who smoke during pregnancy have a 33% reduced risk of developing PE. This reduced risk is hypothesized to be, in part, attributed to carbon monoxide (CO), a by-product of cigarette combustion and a known endogenous vasodilator. Determining the vascular effects of CO in healthy women, may inform how CO can improve endothelial function and have promise as a novel therapeutic for PE. As part of a pilot study to determine the vascular effects of CO, the aim of this study was to measure microvascular vasodilation following low-dose CO inhalation. Non-pregnant women inhaled ambient room air or 250 ppm CO for 24 min during microvascular assessment using laser speckle contrast imaging. Changes in vascular flux were measured in the forearm before, during, and following a three-minute arterial occlusion. CO inhalation increased end-tidal breath CO (EtCO) (9.1 ± 1.9 vs. 1.8 ± 0.7 ppm, p 0.05) and increased microvascular vasodilation, measured as difference of maximum level/resting level ratio (mean difference 0.476, 95% confidence interval (CI) = 0.149-0.802 vs. 0.118, 95% CI = -0.425-0.662, p 0.05). Women who inhaled CO had a longer time to half recovery of endothelial function following arterial occlusion, compared to controls (hazard ratio 0.29, 95% CI = 0.10-0.91, p = 0.033). Inhalation of CO moderately increased EtCO and resulted in an increased microvascular response, suggesting that CO may have potential as a therapeutic for PE.

Objective Induced abortion is the second most common reproductive health procedure in Canada. Among all Canadian women, 31% will have at least one induced abortion in their life. Unfortunately, abortion services are disparate throughout the country. With the recent introduction of mifepristone in Canada, it is hoped that access to abortion will be improved. However, it is recognized that some women who are eligible for medical abortion with mifepristone will still choose surgical abortion. The purpose of this study was to understand the patient's motivation to choose surgical abortion instead of medical abortion. Methods A survey was given to a sample of women coming to the Women's Clinic at Kingston General Hospital in Kingston, Ontario, for surgical abortion who qualified for medical abortion at the time their appointment was made. The study was approved by the Queen's University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board before data collection (#6022783) (Canadian Task Force Classification II-2). Results This study was conducted between February 13, 2018 and June 1, 2018. In agreement with previous studies, the most common perceived advantages of surgical abortion were that it is faster and requires fewer visits. Therefore, one of the greatest perceived obstacles to medical abortion is the need for follow-up. Conclusion Being able to offer two highly effective options for induced abortion will hopefully improve equitable access to abortion. To increase women's acceptance of medical abortion as a feasible option, we need to consider making some changes to the follow-up plan in our clinic.

Cardiovascular disease (CVD) is the leading cause of death and disability among women, with more than half occurring in individuals with hypertension. New blood pressure criteria for the diagnosis of hypertension from the American College of Cardiology/American Heart Association recognize that there is no specific blood pressure threshold that is associated with vascular disease. We performed a secondary analysis of two published postpartum databases (the Pre-Eclampsia New Emerging Team [PE-NET] cohort and the Maternal Health Clinic [MHC] cohort) to determine the impact of the change in blood pressure criteria on the diagnosis of hypertension. The prevalence of hypertension in women with uncomplicated pregnancies (PE-NET control) was 22% compared with 56.4% in those who have had a pregnancy complicated by preeclampsia (PE, PE-NET patient) and 67.2% in those referred to the MHC due to a pregnancy complicated by any of the hypertensive disorders of pregnancy. It is well established that certain complications in pregnancy can reliably identify women with risk factors for future CVD. Thus, pregnancy and the postpartum afford a new opportunity for cardiovascular risk screening that could lead to lifestyle modification and therapeutic intervention. Applying the new guideline criteria at least doubles the prevalence of women with hypertension postpartum.

Hypertensive disorders of pregnancy (HDP) comprise an independent, sex-specific risk factor for cardiovascular disease (CVD) in women. This study examined the utility of CVD risk models proposed in the 2016 Canadian Cardiovascular Society (CCS) lipid guidelines to identify women requiring further screening or lipid treatment following HDP.Using data collected from the postpartum Maternal Health Clinic (MHC) at Kingston General Hospital in Kingston, Ontario and the Preeclampsia New Emerging Team (PE-NET) cohort study, the study investigators used the models recommended by the CCS guidelines and the cardiometabolic model of life expectancy in each cohort to estimate CVD risk in women after HDP. (Canadian Task Force Classification II-2).Using the 10-Year Modified Framingham Risk Score, all women were classified by the 2016 CCS Guidelines as low risk, requiring no follow-up. The 30-Year and Lifetime Risk Scores resulted in significant reclassification of women at risk in the PE-NET control and HDP groups (P 0.001 and P 0.0001, respectively); 49.2% of women with HDP were classified as high risk, requiring follow-up, compared with 14.3% of control subjects. Using the cardiometabolic model, median life expectancy was significantly lower and expected onset of CVD was earlier in the HDP group compared with the control group (P 0.0001).The 2016 CCS lipid guidelines' risk classification recommendations significantly underestimated lifelong CVD risk in the HDP group compared with the control group. Women with HDP also had a significant decrease in cardiometabolic life expectancy and an earlier predicted age at onset of CVD. Early primary prevention in this at-risk population may improve CVD outcomes and reduce the future burden on the health care system.

Objectives This study aims to identify risk factors of PUR and validatea screening protocol proposed by Meekins et al. (Southern Medical Journal. 110(12):785-790, 2017 12.), where PUR is defined as a 1st void 100ml. Methods A retrospective chart review of all POP procedures performed by a urogynecologist at an academic centre between May 2011-June 2017 was conducted. The rate of PUR was determined based on our centre's protocol (voided volume >200ml without voiding difficulty symptoms, or PVR Results 153 patient charts (Age=65±13 years) were reviewed. Ten patients were excluded due to missing chart, failure to follow local void protocol or pre-existing urinary retention. Based on our protocol, 28.1% of patients experienced acute PUR. An overall advanced prolapse (stage ?3) was the only significant risk factor for retention identified (Adjusted Odds Ratio=4.8, 95% CI [1.2-19.6]). Applying our PUR definition to the Meekins’ algorithm showed the following validity measures for the latter's protocol: sensitivity=64%, specificity=89%, PPV=70%, and NPV=86%. Conclusions Our center's rate of PUR after POP surgery is 28%, with higher rates in women with advanced prolapse. The performance of the Meekins et al. algorithm in our population was not clinically useful nor consistent with previously reported values (sensitivity 99%, specificity 95%, PPV=97%, NPV=97%).

To determine the effect of obesity on decision-to-incision and decision-to-delivery time intervals in emergency Caesarean section.We performed a retrospective study of emergency Caesarean sections performed between 2005 and 2009. Indications for emergency Caesarean section were defined as those posing an immediate threat to the life of the mother or fetus. The primary outcomes were the time intervals from decision for emergency delivery to skin incision, and decision to delivery of the infant. The secondary outcome was a composite of poor neonatal outcomes comprising umbilical cord artery pH lt; 7.20, Apgar score lt; 7 at five minutes, admission to NICU, or neonatal death.A total of 232 women underwent emergency Caesarean section, and 140 of these met the inclusion criteria. At the time of delivery, 78/140 (55.7%) patients were categorized as obese (BMI ≥ 30kg/m2). The median decision-to-incision and decision-to-delivery intervals were significantly longer in the obese group, with a median delay of 4.5 minutes in both time intervals. Time-to-event analysis demonstrated prolongation of the decision-to-incision interval in the obese group (hazard ratio 0.71, P lt; 0.05). There was no difference in the neonatal composite outcome, but there was a significant reduction in median five-minute Apgar score in the obese group (P = 0.02).Obesity is associated with prolonged decision-to-incision and decision-to-delivery intervals, without associated neonatal morbidity, in a tertiary hospital setting. Further studies are required to assess the specific factors limiting expedient delivery in this population.

OBJECTIVES We sought to determine the rates of obstetrical anal sphincter tears (OASIS) between types of obstetrical care providers at Kingston General Hospital (KGH) and in Ontario via the Better Outcomes Registry Network (BORN). METHODS This cross-sectional study collected patient, demographic, and delivery data from all vaginal deliveries at KGH from June 2011 to June 2014 and all vaginal deliveries through the BORN database from June 2012 to June 2014. RESULTS During this period, 4.6% and 3.5% of all vaginal deliveries at KGH and in Ontario, respectively, were complicated by OASIS. The OASIS' rates were not statistically different between admitting care providers at KGH: 4.9%, 3.8%, and 3.7% of vaginal deliveries by obstetricians, family physicians, and midwives, respectively, in contrast to a higher rate of OASIS in women admitted under midwifery care in the province-wide data: 3.4%, 3.2%, and 4.4% for obstetricians, family physicians, and midwives, respectively. The rate of OASIS in patients who had an intrapartum transfer of care (TOC) from a family physician or midwife to an obstetrician was 13.8% at KGH, and 13.6% as reported by BORN, significantly higher than 3.8% (KGH) or 2.9% (BORN) in those who remained under the family physician, or midwife. The relative risk of OASIS in women transferred to an obstetrician compared to those who were admitted and delivered by an obstetrician was 3.9 (95% confidence interval, 3.6-4.3, P < 0.0001). CONCLUSIONS Only when an intrapartum TOC is needed does the OASIS rate substantially increase, reflecting the underlying indication for TOC is leading to more intervention associated with risk of OASIS.

Objectives To determine whether delaying the fetal anatomy assessment based on maternal body mass index (BMI) reduces the rate of inadequate visualization at initial scan and subsequent repeat examinations when compared to standard timing at 18-20 weeks’ gestation. Methods A retrospective study of singleton anatomy assessments between 16-24 weeks’ gestation at a single centre comparing the two-year period before (A) and after (B) protocol initiation. Multivariate logistic regression was used to examine the odds of inadequate visualization and need for repeat examination between time periods. Per-protocol and BMI subgroup analyses were completed. Results 3,571 pregnancies in A and 3,749 in B were included. In B, 72.8% were scheduled per-protocol; however, the rate decreased for higher BMI categories (50.9% for BMI ?40 kg/m2). The rate of inadequate visualization (20.8% vs. 20.3%) and the rate of repeat examination (10.4% vs. 11.2%) did not differ significantly (P>0.05). Multivariate logistic regression done on all and per-protocol pregnancies did not detect a significant difference in odds of inadequate visualization or repeat examination in B. In subgroup analysis, a significant decrease in odds of repeat examination in B (OR=0.44, 95%CI=0.23;0.84) was detected only for BMI ?40kg/m2 (P Conclusions A protocol that schedules the fetal anatomy assessment based on maternal BMI did not decrease the rate of inadequate visualization. A reduction in the odds of repeat examinations in pregnancies with class 3 obesity was seen; however, there is insufficient evidence to support the delay of the anatomy assessment after 20+6 weeks in obese pregnancies.

Objectives To evaluate the prevalence of regret with the decision to undergo a hysterectomy at a young age ( Methods All hysterectomies performed at two tertiary level academic centers for benign indications between Jan. 1, 2008 and Dec.31, 2015 were included. A retrospective chart review was performed to assess patient demographics, clinical history and indication for surgery. A validated decision regret survey and an additional patient health questionnaire were administered. Results We identified 189 patients that met the inclusion criteria. Of the 95 patients who we were able to contact, 71 consented to participate in the study and completed the survey (response rate: 75%). The most common indications for surgery were: menorrhagia (35.2%), uterine fibroids (22.5%), endometriosis (19.7%), and pain (15.5%). Overall, 91.5% of patients agreed or strongly agreed that having this surgery was the right decision for them and 90% said that they would make the same choice in the future. Only 2.8% regretted the choice that they made and 14% responded that the decision to proceed with a hysterectomy caused them harm. Over 95% of patients reported that the decision to proceed with a hysterectomy was either mostly patient driven or shared with the physician and 20.2% reported that this decision was difficult. Conclusions This is the first evaluation of regret post hysterectomy specifically examining the younger patient population. Our results suggest that patients who are appropriately counselled do not regret their decision to proceed with hysterectomy.

For women of reproductive age, excessive gestational weight gain and/or postpartum weight retention can increase the risk of obesity. This systematic review evaluates the effectiveness of lifestyle modification control trials that utilize exercise interventions, with or without dietary intervention, on weight loss among postpartum women. A search of randomized clinical trials (RCT) was performed using the follow databases and the bibliography of candidate studies: MEDLINE, Web of Science, EMBASE, CENTRAL/Cochrane and Physiotherapy Evidence Database. English language RCT papers published up to 31 October 2012, which present changes on maternal body weight from baseline to the end of exercise intervention were included. The primary meta-analysis examined the effects of exercise interventions, with or without complementary dietary intervention, on weight loss during the postpartum period compared with usual standard of care. Five subgroup analyses were performed to examine differences in study interventions and exercise modalities: duration of intervention, quality of study methodology, supervision of exercise intervention, exercise intervention goals used and the type of dietary intervention. In total 11 studies met eligibility criteria with 769 participants, 409 under intervention and 360 in the control group. The primary meta-analysis included all 11 studies and found a mean difference (MD) on weight loss of -2.57 kg (95% CI -3.66 to -1.47). The subgroup analysis demonstrated that the most effective interventions in reducing weight in postpartum women were exercise programs with objectively defined goals, such as the use of heart rate monitors or pedometer (MD of -4.09 kg-95% CI -4.94 to -3.25, I(2)=0%) and exercise combined with intensive dietary intervention (MD of -4.34 kg-95% CI -5.15 to -3.52, I(2)=0%). Thus, there is benefit from overall lifestyle interventions on weight loss in postpartum women and exercise plus intensive diet and objective targets are the most effective intervention strategies.