Search

Background One of the controversies in the management of twin gestations relates to mode of delivery, especially when the second twin is in a nonvertex presentation (Vertex/nonVertex pairs) and birth is imminent at extremely low gestation. Objective We hypothesized that, for Vertex/nonVertex twins born before 28 weeks’ gestation, cesarean delivery would be associated with a lower risk of adverse neonatal outcomes than trial of vaginal delivery. Our aim was to test this hypothesis by comparing the neonatal outcomes of Vertex/nonVertex twins born before 28 weeks’ gestation by mode of delivery using a large national cohort. Study Design This work is a retrospective cohort study of all twin infants born at 240/7 to 276/7 weeks’ gestation and admitted to level III neonatal intensive care units participating in the Canadian Neonatal Network (2010–2017). Exposure is defined a trial of vaginal delivery for Vertex/nonVertex twins. Nonexposed (control) groups are defined as cases where both twins were delivered by cesarean delivery, either in vertex or nonvertex presentation (control group 1) or owing to the nonvertex presentation of the first twin (control group 2). Outcome measures are defined as a composite of neonatal death, severe neurologic injury, or birth trauma. Results A total of 1082 twin infants (541 twin pairs) met the inclusion criteria: 220 Vertex/nonVertex pairs, of which 112 had a trial of vaginal delivery (study group) and 108 had cesarean delivery for both twins (control group 1); 170 pairs with the first twin in nonvertex presentation, all of which were born by cesarean delivery (control group 2); and 151 pairs with both twins in vertex presentation (vertex or nonvertex). In the study group, the rate of urgent cesarean delivery for the second twin was 30%. The rate of the primary outcome in the study group was 42%, which was not significantly different compared with control group 1 (37%; adjusted relative risk, 0.93; 95% confidence interval, 0.71–1.22) or control group 2 (34%; adjusted relative risk, 1.20; 95% confidence interval, 0.92–1.58). The findings remained similar when outcomes were analyzed separately for the first and second twins. Conclusion For preterm Vertex/nonVertex twins born at

Objective The purpose of this study was to evaluate pregnancy outcomes in a cohort of women with a placental edge between 11 and 20mm from the internal cervical os, and to determine the likelihood of a successful vaginal delivery when trial of labour is attempted in these women. Methods We carried out a prospective observational study of women with singleton pregnancies and a placental edge between 11 and 20mm from the internal cervical os (identified by transvaginal sonography) who underwent a trial of labour. Results Fourteen women with the above characteristics underwent a trial of labour during the study period. The mean interval (± SD) from ultrasound to delivery was 17.2±9.6 days. Thirteen women (92.9%) delivered vaginally with no complications, and only one woman (7.1%) required an emergency Caesarean section for intrapartum bleeding. The risks of antepartum and postpartum hemorrhage were 21.4% and 14.3%, respectively. Conclusion Having a placental edge more than 10mm from the internal os, measured by transvaginal sonography near term, justifies allowing a trial of labour and carries a low risk of subsequent obstetrical hemorrhage.

Objective We reviewed cases of group B Streptococcus (GBS) sepsis in term infants at our institution to identify areas for potential prevention. Methods We identified cases by searching our institution's microbiology databases for all positive GBS blood and cerebrospinal fluid cultures taken from infants between 2008 and 2013. Patients were included if the timing of the positive culture met the criteria for early-onset GBS disease (age 7 days or under). Charts that met inclusion criteria were abstracted for details related to antepartum screening, intrapartum care, and postpartum outcome. Results There are an average of 10 000 deliveries per year in our institution. During the five-year period (2008–2013), we identified 13 cases representing early-onset GBS disease in term infants. Of the 13 cases, nine mothers screened negative for GBS, two screened positive, and two were screened unknown. Four cases qualified for intrapartum prophylaxis; of these, two did not receive appropriate prophylaxis, one because of parental refusal and one for unspecified reasons after the membranes had been ruptured for > 18 hours. All 13 infants had confirmed GBS bacteremia, and four had concurrent GBS meningitis. One infant died and one infant had neurologic sequelae. Conclusion Early-onset GBS disease in term infants continues to occur at our institution, and consequences for the infant can be severe. The majority of cases identified were screened and managed in accordance with current guidelines. Most cases were GBS negative when screened in the antepartum period, raising the question of whether a more sensitive test or a test closer to delivery could prevent further cases of early-onset GBS disease.

Background Cerebral cavernous malformations are brain vascular malformations associated with intracranial hemorrhage. It is unclear whether pregnancy is a risk factor for hemorrhage, yet there is speculation that it may be. Objective To compare the risk of clinically significant hemorrhage during pregnancy and nonpregnancy. Methods A total of 186 patients from the University of Toronto Vascular Malformations Study Group were enrolled. The obstetrical history of each patient was collected and matched to their neurological history from the records of the study group. All hemorrhagic events occurring during childbearing years were associated with either a defined pregnancy risk period or nonpregnancy period. Patients were also asked to recall advice that they received from health care professionals regarding risk of hemorrhage in pregnancy. Results Among our patient population there were 349 pregnancies (283 live births) and 49 hemorrhages during childbearing years, 3 of which were during pregnancy but none during delivery or within 6 weeks post partum. The hemorrhage rate for pregnant women was 1.15% (95% confidence interval: 0.23-3.35) per person-year and 1.01% (95% confidence interval: 0.75-1.36) per person-year for nonpregnant women. Relative risk of pregnancy was 1.13 (95% confidence interval: 0.34-3.75) (P = .84). Neurosurgeons and obstetricians were the source of most hemorrhage risk advice. The majority of neurosurgeons suggested that the risk was unchanged, but the obstetricians were divided. Four patients never conceived, and 2 others began contraception because of the advice that they received. Conclusion The risk of intracranial hemorrhage from cerebral cavernous malformations is likely not changed during pregnancy, delivery, or post partum.

Background Urgent delivery of the fetus is often considered as the treatment of choice for mothers in their second or third trimester with hepatitis unique to pregnancy (HUP). Objective To determine whether standard liver function tests (serum bilirubin and international normalized ratio levels) help to identify mothers and their newborns who might benefit from early delivery. Methods A total of 149 patients with HUP were retrospectively classified as those with normal (stable-HUP, n=118) or abnormal (progressive-HUP, n=31) liver function tests. Clinical outcomes consisted of maternal lengths of hospital stay after delivery and neonatal appearance, pulse, grimace, activity, respiration score ratings at 0 and 5 min. Results Patients with stable-HUP had similar lengths of hospital stay after delivery whether delivered early (4.8±3.4 days) or at term (4.8±3.6 days). Appearance, pulse, grimace, activity, respiration score ratings at birth were similar in neonates from patients with stable-HUP delivered prematurely (5.8±2.7) and at term (7.8±1.7, P=0.48) but significantly higher at 5 min in those delivered at term (7.5±2.0 vs. 8.9±0.3, P=0.003). Too few patients with progressive-HUP were delivered at term (N=4) to allow similar comparisons in this cohort. Conclusion The results of this study indicate that mothers with HUP and normal liver function tests (bilirubin and international normalized ratio) can be safely followed to term without jeopardizing the health of either mother or neonates. Additional studies are required to determine whether abnormal liver function tests represent an indication for immediate delivery of the fetus in mothers with HUP.

Objective To review the effect of the number of embryos transferredon the outcome of in vitro fertilization (IVF), to provide guidelineson the number of embryos to transfer in IVF-embryo transfer (ET)in order to optimize healthy live births and minimize multiplepregnancies. Options Rates of live birth, clinical pregnancy, and multiplepregnancy or birth by number of embryos transferred arecompared. Outcomes Clinical pregnancy, multiple pregnancy, and live birthrates. Evidence The Cochrane Library and MEDLINE were searched forEnglish language articles from 1990 to April 2006. Search termsincluded embryo transfer (ET), assisted reproduction, in vitrofertilization (IVF), intracytoplasmic sperm injection (ICSI), multiplepregnancy, and multiple gestation. Additional references wereidentified through hand searches of bibliographies of identifiedarticles. Values Available evidence was reviewed by the ReproductiveEndocrinology and Infertility Committee and the Maternal-FetalMedicine Committee of the Society of Obstetricians andGynaecologists of Canada and the Board of the Canadian Fertilityand Andrology Society, and was qualified using the Evaluation ofEvidence Guidelines developed by the Canadian Task Force onthe Periodic Health Exam. Benefits, Harms, and Costs This guideline is intended to minimizethe occurrence of multifetal gestation, particularly high-ordermultiples (HOM), while maintaining acceptable overall pregnancyand live birth rates following IVF-ET. Recommendations The recommendations made in this guideline were derived mainlyfrom studies of cleavage stage embryos—those cultured for two orthree days. 1.Individual IVF-ET programs should evaluate their own data toidentify patient-specific, embryo-specific, and cycle-specificdeterminants of implantation and live birth in order to developembryo transfer policies that minimize the occurrence of multifetalgestation while maintaining acceptable overall pregnancy and livebirth rates. (III-B) 2.In general, consideration should be given to the transfer of fewerblastocyst stage embryos than cleavage stage embryos,particularly in women with excellent prognoses and high-qualityblastocysts. (I-A) 3.In women under the age of 35 years, no more than two embryosshould be transferred in a fresh IVF-ET cycle. (II-2A) 4.In women under the age of 35 years with excellent prognoses, thetransfer of a single embryo should be considered. Women withexcellent prognoses include those undergoing their first or secondIVF-ET cycle or one immediately following a successful IVF-ETcycle, with at least two high-quality embryos available for transfer.(I-A) 5.In women aged 35 to 37 years, no more than three embryos shouldbe transferred in a fresh IVF-ET cycle. In those with high-qualityembryos and favourable prognoses, consideration should be givento the transfer of one or two embryos in the first or second cycle.(II-2A) 6.In women aged 38 to 39 years, no more than three embryos shouldbe transferred in a fresh IVF-ET cycle. (III-B) In those withhigh-quality embryos and favourable prognoses, considerationshould be given to the transfer of two embryos in the first orsecond cycle. (III-B) 7.In women over the age of 39 years, no more than four embryosshould be transferred in a fresh IVF-ET cycle. (III-B) In those olderwomen with high-quality embryos in excess of the number to betransferred, consideration should be given to the transfer of threeembryos in the first IVF-ET cycle. (III-B) 8.In exceptional cases when women with poor prognoses have hadmultiple failed fresh IVF-ET cycles, consideration may be given tothe transfer of more embryos than recommended above insubsequent fresh IVF-ET cycles. (III-C) 9.In donor–recipient cycles, the age of the oocyte/embryo donorshould be used when determining the number of embryos totransfer. (II-2B) 10.In women with obstetrical or medical contraindication to multifetalgestation, fewer embryos should be transferred to minimize thechance of multifetal gestation. In such cases, pre-treatmentconsultation with a maternal-fetal medicine specialist should be pursued. (III-C) Whenever reasonable, consideration should begiven to the transfer of a single embryo. (II-3B) 11.Couples should be adequately counselled regarding theobstetrical, perinatal, and neonatal risks of multifetal gestation tofacilitate informed decision making regarding the number ofembryos to transfer. (II-3B) Emphasis on healthy singleton livebirth as the measure of success in IVF-ET may be beneficial inpromoting a reduction in the number of embryos transferred. (III-C) 12.A strategy for public funding of IVF-ET must be developed for theeffective implementation of guidelines limiting the number ofembryos transferred. In the context of this strategy, total healthcare costs would be lower as a result of reductions in the incidenceof multifetal pregnancies and births. (III-C) 13.Efforts should be made to limit iatrogenic multiple pregnanciesresulting from non–IVF-ET ovarian stimulation through thedevelopment of suitable guidelines for cycle cancellation and theremoval of financial barriers to IVF-ET. (III-B) Summary Statement The following recommendations are generally intended forcleavage stage embryos transferred on day two or three. Because blastocyst stage embryos have higher implantation rates thancleavage stage embryos, fewer blastocyst stage embryos mayneed to be transferred. (II) Validation This guideline was reviewed by the ReproductiveEndocrinology and Infertility Committee and the Maternal-FetalMedicine Committee and approved by the Executive and Councilof the Society of Obstetricians and Gynaecologists of Canada andthe Board of the Canadian Fertility and Andrology Society. Sponsor Society of Obstetricians and Gynaecologists of Canada.The quality of evidence reported in this document has beendescribed using the Evaluation of Evidence criteria outlined in theReport of the Canadian Task Force on the Periodic Health Exam(Table 1).

A 13-year-old primigravida underwent ultrasound assessment at 24+4 weeks’ gestation. In the fetal head, echogenic areas were seen in the right frontal lobe adjacent to the lateral ventricle (Figure 1). MRI confirmed that this was an intraparenchymal hemorrhage (Figure 2). Labour was induced at 26+4 weeks, and a stillborn male fetus was delivered. Autopsy confirmed a large right-sided subacute ganglionic eminence hemorrhage involving the parenchyma in the parietal and posterior frontal regions.

Background During the influenza pandemic of spring 2009, Manitoba had a disproportionate number of pregnant women who became critically ill. Information about these cases will be useful to help us understand the potential impact of future outbreaks and review critical illness in pregnancy. Methods We describe the clinical details of six critically ill pregnant women with pandemic H1N1 2009 influenza virus admitted to two ICUs in Manitoba between March 1 and August 31, 2009. Results Thirty adult pregnant women tested positive for pandemic H1N1 2009 virus in Manitoba. Six women were admitted to the ICU. The time from onset of symptoms to life-threatening deterioration was on average five days. Most patients presented with worsening fever and cough and had H1N1-positive contacts. Five of six patients (83%) were Aboriginal. Four of six cases occurred in the third trimester. These patients frequently required non-conventional ventilatory support such as high frequency ventilation or extracorporeal membrane oxygenation (ECMO). All patients received oseltamivir. Two patients died while in the ICU. Three of six patients had adverse perinatal outcomes, and there was one spontaneous abortion and one early preterm delivery. Conclusion Pandemic H1N1 2009 influenza virus has the potential to cause severe illness in pregnant patients. Those patients requiring ICU admission for respiratory support have a high risk for poor fetal and neonatal outcome. The experience of this cohort underscores the appropriateness of public health measures directed at prevention and early treatment of H1N1 infection in pregnancy.

Objectives To assess the benefits and risks of antenatal corticosteroid therapy for fetal maturation. Options To administer antenatal corticosteroids or not to women at risk of preterm birth. Outcomes Perinatal morbidity, including: respiratory distress syndrome, intraventricular hemorrhage, infection, adrenal suppression, somatic and brain growth; perinatal mortality; and maternal morbidity, including infection and adrenal suppression. Evidence MEDLINE and PubMed searches 1996 to August 2002 for English-language articles related to antenatal corticosteroid therapy for fetal maturation, the Cochrane Library, and national statements including that of the National Institutes of Health (NIH), the American College of Obstetricians and Gynecologists, and the Royal College of Obstetricians and Gynaecologists. Values The evidence obtained was reviewed and evaluated by the Maternal-Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and recommendations were made according to guidelines developed by the Canadian Task Force on the Periodic Health Exam. BENEFITS AND HARMS: A single course of corticosteroids reduces perinatal mortality, respiratory distress syndrome, and intraventricular hemorrhage. Information regarding repeat courses of corticosteroids is limited and conflicting, with many studies being retrospective and non-randomized. Some studies suggested a reduction in respiratory distress syndrome with repeat courses, but some found increased rates of neonatal and maternal infection; fetal, neonatal, and maternal adrenal suppression; decreased fetal or neonatal somatic and brain growth; and increased perinatal mortality. Recommendations The SOGC supports the recommendations of the NIH Consensus Development Panel: 1. All pregnant women between 24 and 34 weeks' gestation who are at risk of preterm delivery within 7 days should be considered candidates for antenatal treatment with a single course of corticosteroids. (I-A) 2. Treatment should consist of two 12 mg doses of betamethasone given IM 24 hours apart, or four 6 mg doses of dexamethasone given IM 12 hours apart (I-A). There is no proof of efficacy for any other regimen. 3. Because of insufficient scientific data from randomized clinical trials regarding efficacy and safety, repeat courses of corticosteroids should not be used routinely (II-2E) but be reserved for women participating in randomized controlled trials. Validation This Committee Opinion has been reviewed and approved by the Maternal-Fetal Medicine Committee of the SOGC and approved by SOGC Council.

Objective The purpose of this study was to evaluate the phenomenon of vascular ischemic limb necrosis in twin-twin transfusion syndrome (TTTS). Study Design This was a multicenter retrospective review of ischemic limb necrosis in patients with TTTS. Results Twenty cases of fetal ischemic limb necrosis in association with TTTS were identified from 10 fetal medicine centers. The recipient was affected in 19 cases, and the lower limb was affected in 17 cases. The extent of the damage correlated with TTTS severity. Eighty percent of limb defects (16/20) clearly were unrelated to laser treatment (3 cases untreated, 7 cases after amnioreduction, 6 cases present at time of laser). The recipient was relatively polycythemic in 5 of 7 cases in which neonatal or fetal hemoglobin/hematocrit levels were available. Conclusion Ischemic limb necrosis is a rare complication of TTTS. The lesion is unrelated to therapy and may be the result of polycythemia, hypertension, and vasoconstriction.

The C677T MTHFR variant has been associated with the same third trimester pregnancy complications as seen in women who have elevations of maternal serum α-fetoprotein (MSAFP). We hypothesized that these women with third trimester pregnancy complications and MSAFP elevations would have an increased frequency of the variant compared to an abnormal study control group (women with MSAFP elevations without pregnancy complications) as well as to normal population controls. Women who had unexplained elevations of MSAFP in pregnancy were ascertained retrospectively. The frequency of the C677T MTHFR variant among those women with unexplained elevations of MSAFP who had experienced later pregnancy complications was compared to that of women with unexplained elevations of MSAFP without complications as well as to that of the previously established Manitoba frequency. Women who had complications of pregnancy and an unexplained MSAFP elevation had a higher allele frequency for the C677T MTHFR variant (q = 0.36,) compared to women with MSAFP elevations and normal pregnancy outcomes (q = 0.25, OR 1.73 95% CI 1.25–2.37, p = 0.03). The frequency was also higher than that of the population controls (q= 0.25, OR 1.70 95% CI 1.11–2.60, p = 0.007). The frequency in women with MSAFP elevations without pregnancy complications was not significantly different from that of the population controls (p = 0.41). Women with unexplained elevations of MSAFP and who experience complications in later pregnancy are more likely to have one or two alleles of the C677T MTHFR variant.