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Javid N, Donnolley N, Kingdom J, Dadouch R, D'Souza R. Women- and clinician- important outcomes and priorities regarding vasa praevia: An international qualitative study to inform development of a core outcome set. Women Birth 2024; 37:101614. [PMID: 38669723 DOI: 10.1016/j.wombi.2024.101614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Many studies have reported interventions for women with vasa praevia to improve perinatal outcomes. However, which outcomes are important for women remains unclear. AIM To explore what outcomes are important for women with lived experience of vasa praevia and why, in order to inform the development of a core outcome set for studies on vasa praevia. METHODS An international qualitative study was conducted with women and clinicians. Semi-structured interviews were audio-recorded, transcribed, and analysed taking an inductive approach. FINDINGS Eighteen women and six clinicians (four obstetricians, two midwives) from the United States, United Kingdom, Canada, and Australia were interviewed. Participants identified 47 patient-important outcomes and experience measures, which were grouped under five themes: baby's survival and health, mother's physical health, mother's mental and emotional health, quality of health care delivery, and resource use and cost. While survival of the baby without short- and long-term morbidity remained the main priority, other important considerations included the physical, mental, social and financial wellbeing of families, future access to antenatal screening and diagnosis, information on management options and consequences, continuity of care, clear and effective communication, peer support and the appreciation of individual variations to risk tolerance, values and resource availability. CONCLUSION We have identified patient-important outcomes and experience measures that have been directly fed into the development of a core outcome set on vasa previa. Incorporating these considerations into both clinical practice and future research studies has the potential to improve outcomes and experiences for women with vasa praevia.
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Affiliation(s)
- Nasrin Javid
- Faculty of Health, University of Technology Sydney, 235-253, Jones Street, Ultimo, Sydney, New South Wales 2007, Australia; Sydney Institute for Women, Children, and their Families, Sydney, 83 Missenden Road, Camperdown, New South Wales 2050, Australia.
| | - Natasha Donnolley
- Faculty of Medicine and Health, University of New South Wales, Sydney, Botany street, Kensington, New South Wales 2033, Australia
| | - John Kingdom
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, 600 University Avenue, Ontario, Toronto M5G 1×5, Canada
| | - Rachel Dadouch
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, 600 University Avenue, Ontario, Toronto M5G 1×5, Canada
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, 600 University Avenue, Ontario, Toronto M5G 1×5, Canada; Departments of Obstetrics & Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, 1280 Main St. West, Hamilton, Ontario L8S 4K1, Canada
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McCann ZH, Chang HH, D'Souza R, Scovronick N, Ebelt S. Assessment of census-tract level socioeconomic position as a modifier of the relationship between short-term PM 2.5 exposure and cardiovascular emergency department visits in Missouri. J Epidemiol Community Health 2024; 78:296-302. [PMID: 38302278 PMCID: PMC11006568 DOI: 10.1136/jech-2023-221438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/16/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Ambient particulate matter ≤ 2.5 µm in aerodynamic diameter (PM2.5) exposure elevates the risk for cardiovascular disease morbidity (CVDM). The aim of this study is to characterise which area-level measures of socioeconomic position (SEP) modify the relationship between PM2.5 exposure and CVDM in Missouri at the census-tract (CT) level. METHODS We use individual level Missouri emergency department (ED) admissions data (n=3 284 956), modelled PM2.5 data, and yearly CT data from 2012 to 2016 to conduct a two-stage analysis. Stage one uses a case-crossover approach with conditional logistic regression to establish the baseline risk of ED visits associated with IQR changes in PM2.5. In the second stage, we use multivariate metaregression to examine how CT-level SEP modifies the relationship between ambient PM2.5 exposure and CVDM. RESULTS We find that overall, ambient PM2.5 exposure is associated with increased risk for CVDM. We test effect modification in statewide and urban CTs, and in the warm season only. Effect modification results suggest that among SEP measures, poverty is most consistently associated with increased risk for CVDM. For example, across Missouri, the highest poverty CTs are at an elevated risk for CVDM (OR=1.010 (95% CI 1.007 to 1.014)) compared with the lowest poverty CTs (OR=1.004 (95% CI 1.000 to 1.008)). Other SEP modifiers generally display an inconsistent or null effect. CONCLUSION Overall, we find some evidence that area-level SEP modifies the relationship between ambient PM2.5 exposure and CVDM, and suggest that the relationship between air-pollution, area-level SEP and CVDM may be sensitive to spatial scale.
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Affiliation(s)
- Zachary H McCann
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Howard H Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory Univeristy, Atlanta, Georgia, USA
| | - Rohan D'Souza
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory Univeristy, Atlanta, Georgia, USA
| | - Noah Scovronick
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Stefanie Ebelt
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Oyelese Y, Javinani A, Gudanowski B, Krispin E, Rebarber A, Akolekar R, Catanzarite V, D'Souza R, Bronsteen R, Odibo A, Scheier MA, Hasegawa J, Jauniaux E, Lees C, Srinivasan D, Daly-Jones E, Duncombe G, Melcer Y, Maymon R, Silver R, Prefumo F, Tachibana D, Henrich W, Cincotta R, Shainker SA, Ranzini AC, Roman AS, Chmait R, Hernandez-Andrade EA, Rolnik DL, Sepulveda W, Shamshirsaz AA. Vasa previa in singleton pregnancies: diagnosis and clinical management based on an international expert consensus. Am J Obstet Gynecol 2024:S0002-9378(24)00442-3. [PMID: 38494071 DOI: 10.1016/j.ajog.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/01/2024] [Accepted: 03/09/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND There are limited data to guide the diagnosis and management of vasa previa. Currently, what is known is largely based on case reports or series and cohort studies. OBJECTIVE This study aimed to systematically collect and classify expert opinions and achieve consensus on the diagnosis and clinical management of vasa previa using focus group discussions and a Delphi technique. STUDY DESIGN A 4-round focus group discussion and a 3-round Delphi survey of an international panel of experts on vasa previa were conducted. Experts were selected on the basis of their publication record on vasa previa. First, we convened a focus group discussion panel of 20 experts and agreed on which issues were unresolved in the diagnosis and management of vasa previa. A 3-round anonymous electronic survey was then sent to the full expert panel. Survey questions were presented on the diagnosis and management of vasa previa, which the experts were asked to rate on a 5-point Likert scale (from "strongly disagree"=1 to "strongly agree"=5). Consensus was defined as a median score of 5. Following responses to each round, any statements that had median scores of ≤3 were deemed to have had no consensus and were excluded. Statements with a median score of 4 were revised and re-presented to the experts in the next round. Consensus and nonconsensus statements were then aggregated. RESULTS A total of 68 international experts were invited to participate in the study, of which 57 participated. Experts were from 13 countries on 5 continents and have contributed to >80% of published cohort studies on vasa previa, as well as national and international society guidelines. Completion rates were 84%, 93%, and 91% for the first, second, and third rounds, respectively, and 71% completed all 3 rounds. The panel reached a consensus on 26 statements regarding the diagnosis and key points of management of vasa previa, including the following: (1) although there is no agreement on the distance between the fetal vessels and the cervical internal os to define vasa previa, the definition should not be limited to a 2-cm distance; (2) all pregnancies should be screened for vasa previa with routine examination for placental cord insertion and a color Doppler sweep of the region over the cervix at the second-trimester anatomy scan; (3) when a low-lying placenta or placenta previa is found in the second trimester, a transvaginal ultrasound with Doppler should be performed at approximately 32 weeks to rule out vasa previa; (4) outpatient management of asymptomatic patients without risk factors for preterm birth is reasonable; (5) asymptomatic patients with vasa previa should be delivered by scheduled cesarean delivery between 35 and 37 weeks of gestation; and (6) there was no agreement on routine hospitalization, avoidance of intercourse, or use of 3-dimensional ultrasound for diagnosis of vasa previa. CONCLUSION Through focus group discussion and a Delphi process, an international expert panel reached consensus on the definition, screening, clinical management, and timing of delivery in vasa previa, which could inform the development of new clinical guidelines.
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Affiliation(s)
- Yinka Oyelese
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Harvard Medical School, Boston, MA.
| | - Ali Javinani
- Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Harvard Medical School, Boston, MA
| | - Brittany Gudanowski
- Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Eyal Krispin
- Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Andrei Rebarber
- Division of Maternal Fetal Medicine, Mount Sinai West, New York, NY; Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY; Carnegie Imaging for Women, PLLC, New York, NY
| | - Ranjit Akolekar
- Medway Fetal and Maternal Medicine Centre, Medway NHS Foundation Trust, Gillingham, United Kingdom; Institute of Medical Sciences, Canterbury Christ Church University, Chatham, United Kingdom
| | - Val Catanzarite
- Maternal-Fetal Medicine, Rady Children's Specialists of San Diego, San Diego, CA
| | - Rohan D'Souza
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Richard Bronsteen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Corewell Health William Beaumont University Hospital, Royal Oak, MI
| | - Anthony Odibo
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Washington University School of Medicine, St. Louis, MO
| | | | - Junichi Hasegawa
- Department of Perinatal Development Pathophysiology, St. Marianna University Graduate School of Medicine, Kawasaki, Japan
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Christoph Lees
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Institute of Reproductive and Developmental Biology, Imperial College London, London, United Kingdom; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Deepa Srinivasan
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Elizabeth Daly-Jones
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Gregory Duncombe
- Department of Obstetrics and Gynaecology, Logan Hospital, Metro South Health, Meadowbrook, Australia
| | - Yaakov Melcer
- Department of Obstetrics and Gynecology, Shamir Medical Center, Tzrifin, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, Shamir Medical Center, Tzrifin, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert Silver
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Federico Prefumo
- Obstetrics and Gynaecology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Daisuke Tachibana
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Wolfgang Henrich
- Department of Obstetrics, Campus Virchow-Klinikum, Campus Charité Mitte, Universitätsmedizin Berlin, Berlin, Germany; Department of Obstetrics, Charité - University Medical Center, Berlin, Germany
| | - Robert Cincotta
- Department of Maternal Fetal Medicine, Mater Mothers' Hospital, South Brisbane, Australia
| | - Scott A Shainker
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Harvard Medical School, Boston, MA
| | - Angela C Ranzini
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, MetroHealth System, Case Western Reserve University, Cleveland, OH
| | - Ashley S Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY
| | - Ramen Chmait
- Department of Obstetrics & Gynecology, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Edgar A Hernandez-Andrade
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Waldo Sepulveda
- Fetal Imaging Unit, FETALMED Maternal-Fetal Diagnostic Center, Santiago, Chile
| | - Alireza A Shamshirsaz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Harvard Medical School, Boston, MA.
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Keepanasseril A, Pande SN, Satheesh S, Siu SC, D'Souza R. Reply: Risk Estimation in Valvular Heart Disease in Pregnancy. J Am Coll Cardiol 2024; 83:e49. [PMID: 38296409 DOI: 10.1016/j.jacc.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 02/07/2024]
Affiliation(s)
- Anish Keepanasseril
- Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.
| | - Swaraj Nandini Pande
- Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Santhosh Satheesh
- Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Samuel C Siu
- University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada; University of Western Ontario, London, Ontario, Canada
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van den Akker T, D'Souza R, Tura AK, Nair M, Engjom H, Knight M, Donati S. Prioritising actions to address stagnating maternal mortality rates globally. Lancet 2024; 403:417-419. [PMID: 38348648 DOI: 10.1016/s0140-6736(23)02290-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/11/2023] [Indexed: 02/15/2024]
Affiliation(s)
- Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, 2300RC Leiden, Netherlands; Athena Institute, VU University, Amsterdam, Netherlands.
| | - Rohan D'Souza
- Departments of Obstetrics and Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Manisha Nair
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Hilde Engjom
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Norway
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Serena Donati
- National Centre for Disease Prevention and Health Promotion, Istituto Superiore di Sanità, Italian National Health Institute, Rome, Italy
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Park M, Wanigaratne S, D'Souza R, Geoffrion R, Williams S, Muraca GM. Asian-White disparities in obstetric anal sphincter injury: a systematic review and meta-analysis. AJOG Glob Rep 2024; 4:100296. [PMID: 38283323 PMCID: PMC10820309 DOI: 10.1016/j.xagr.2023.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
OBJECTIVE Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately 4.4% of vaginal births in the United States; however, racial and ethnic inequities in the incidence of obstetrical anal sphincter injury have been shown in several high-income countries. Specifically, an increased risk of obstetrical anal sphincter injury in individuals who identify as Asian vs those who identify as White has been documented among residents of the United States, Australia, Canada, Western Europe, and the Scandinavian countries. The high rates of obstetrical anal sphincter injury among the Asian diaspora in these countries are higher than obstetrical anal sphincter injury rates reported among Asian populations residing in Asia. A systematic review and meta-analysis of studies in high-income, non-Asian countries was conducted to further evaluate this relationship. DATA SOURCES MEDLINE, Ovid, Embase, EmCare, and the Cochrane databases were searched from inception to March 2023 for original research studies. STUDY ELIGIBILITY CRITERIA Observational studies using keywords and controlled vocabulary terms related to race, ethnicity and obstetrical anal sphincter injury. All observational studies, including cross-sectional, case-control, and cohort were included. 2 reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Meta-analysis of Observational Studies in Epidemiology recommendations. METHODS Meta-analysis was performed using RevMan (version 5.4; Cochrane Collaboration, London, United Kingdom) for dichotomous data using the random effects model and the odds ratios as effect measures with 95% confidence intervals. Subgroup analysis was performed among Asian subgroups. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools. Meta-regression was used to determine sources of between-study heterogeneity. Results A total of 27 studies conducted in 7 countries met the inclusion criteria encompassing 2,337,803 individuals. The pooled incidence of obstetrical anal sphincter injury was higher among Asian individuals than White individuals (pooled odds ratio, 1.64; 95% confidence interval, 1.48-1.80). Subgroup analyses showed that obstetrical anal sphincter injury rates were highest among South Asians and among population-based vs hospital-based studies. Meta-regression showed that moderate heterogeneity remained even after accounting for differences in studies by types of Asian subgroups included, study year, mode of delivery included, and study setting. Conclusion Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted.
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Affiliation(s)
- Meejin Park
- Faculty of Health Sciences, Department of Global Health, McMaster University, Hamilton, Ontario, Canada (Ms Park)
| | - Susitha Wanigaratne
- Edwin S.H. Leong Centre for Healthy Children, SickKids Research Institute, Toronto, Ontario, Canada (Dr Wanigaratne)
| | - Rohan D'Souza
- Faculty of Health Sciences, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
- Faculty of Health Sciences, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
| | - Roxana Geoffrion
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (Dr Geoffrion)
| | - Sarah Williams
- Department of Anthropology, University of Connecticut, Mansfield, CT (Dr Williams)
| | - Giulia M. Muraca
- Faculty of Health Sciences, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
- Faculty of Health Sciences, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden (Dr Muraca)
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McClymont E, Atkinson A, Albert A, Av-Gay G, Andrade J, Barrett J, Bogler T, Boucoiran I, Castillo E, D'Souza R, El-Chaâr D, Fadel S, Fell DB, Korchinski I, Kuret V, Ogilvie G, Poliquin V, Sadarangani M, Scott H, Snelgrove JW, Tunde-Byass M, Money D. Reactogenicity, pregnancy outcomes, and SARS-CoV-2 infection following COVID-19 vaccination during pregnancy in Canada: A national prospective cohort study. Vaccine 2023; 41:7183-7191. [PMID: 37865598 DOI: 10.1016/j.vaccine.2023.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE To describe self-reported reactogenicity, pregnancy outcomes, and SARS-CoV-2 infection following COVID-19 vaccination during pregnancy. DESIGN National, prospective cohort study. SETTING Participants across Canada were enrolled from July 2021 until June 2022. POPULATION Individuals pregnant during the COVID-19 pandemic, regardless of vaccination status, were included. METHODS The Canadian COVID-19 Vaccine Registry for Pregnant and Lactating Individuals (COVERED) was advertised through traditional and social media. Surveys were administered at baseline, following each vaccine dose if vaccinated, pregnancy conclusion, and every two months for 14 months. Changes to pregnancy or vaccination status, SARS-CoV-2 infections, or significant health events were recorded. MAIN OUTCOME MEASURES Reactogenicity (local and systemic adverse events, and serious adverse events) within 1 week post-vaccination, pregnancy and neonatal outcomes, and subsequent SARS-CoV-2 infection. RESULTS Among 2868 participants who received 1-2 doses of a COVID-19 vaccine during pregnancy, adverse events described included: headache (19.5-33.9%), nausea (4.8-13.8%), fever (2.7-10.2%), and myalgia (33.4-42.2%). Reactogenicity was highest after the 2nd dose of vaccine in pregnancy. Compared to 1660 unvaccinated participants, there were no statistically significant differences in adverse pregnancy or infant outcomes, aside from an increased risk of NICU admission ≥ 24 h among the unvaccinated group. During follow-up, there was a higher rate of participant-reported SARS-CoV-2 infection in the unvaccinated compared to the vaccinated group (18[47.4%] vs. 786[27.3%]). CONCLUSIONS Participant-reported reactogenicity was similar to reports from non-pregnant adults. There was no increase in adverse pregnancy and birth outcomes among vaccinated vs. unvaccinated participants and lower rates of SARS-CoV-2 infection were reported in vaccinated participants. TWEETABLE ABSTRACT No significant increase in adverse pregnancy or infant outcomes among vaccinated versus unvaccinated pregnant women in Canada.
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Affiliation(s)
- E McClymont
- Department of Obstetrics & Gynecology, University of British Columbia, Vancouver, Canada
| | - A Atkinson
- Department of Obstetrics & Gynecology, University of British Columbia, Vancouver, Canada
| | - A Albert
- Women's Health Research Institute, Vancouver, Canada
| | - G Av-Gay
- Department of Obstetrics & Gynecology, University of British Columbia, Vancouver, Canada
| | - J Andrade
- Women's Health Research Institute, Vancouver, Canada
| | - J Barrett
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, Canada
| | - T Bogler
- Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - I Boucoiran
- Department of Obstetrics & Gynecology and School of Public Health, Université de Montréal, Montreal, Canada
| | - E Castillo
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Canada
| | - R D'Souza
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Canada
| | - D El-Chaâr
- Department of Obstetrics & Gynecology, University of Ottawa, Ottawa, Canada
| | - S Fadel
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - D B Fell
- School of Epidemiology & Public Health, University of Ottawa, Ottawa, Canada
| | - I Korchinski
- Women's Health Research Institute, Vancouver, Canada
| | - V Kuret
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Canada
| | - G Ogilvie
- School of Population & Public Health, University of British Columbia, Vancouver, Canada
| | - V Poliquin
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of Manitoba, Winnipeg, Canada
| | - M Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, Canada
| | - H Scott
- Department of Obstetrics & Gynecology, Dalhousie University, Halifax, Canada
| | - J W Snelgrove
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Canada
| | - M Tunde-Byass
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Canada
| | - D Money
- Department of Obstetrics & Gynecology, University of British Columbia, Vancouver, Canada; Women's Health Research Institute, Vancouver, Canada.
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8
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Villani LA, Al‐Torshi R, Shah PS, Kingdom JC, D'Souza R, Keunen J. Inpatient vs outpatient management of pregnancies with vasa previa: A historical cohort study. Acta Obstet Gynecol Scand 2023; 102:1558-1565. [PMID: 37537788 PMCID: PMC10577631 DOI: 10.1111/aogs.14595] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/26/2023] [Accepted: 05/01/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Vasa previa, a condition where unprotected fetal blood vessels lie in proximity to the internal cervical opening, is a potentially lethal obstetric complication. The precarious situation of these vessels increases the risk of fetal hemorrhage with spontaneous or artificial rupture of membranes, frequently causing fetal/neonatal demise or severe morbidity. As a result, in many centers, inpatient management forms the mainstay when vasa previa is diagnosed antenatally. This study aimed to determine whether a subpopulation of pregnancies diagnosed antenatally with vasa previa could be safely managed as outpatients. MATERIAL AND METHODS We reviewed all cases of vasa previa in singleton pregnancies, with no fetal anomalies, diagnosed at Mount Sinai Hospital, Toronto, from January 2008 to December 2017. Cases were categorized into three arms for analysis: outpatients (OP), asymptomatic hospitalized (ASH) and symptomatic hospitalized (SH). The SH arm included patients admitted with any antepartum bleeding or suspicious fetal non-stress test. Those that presented with symptomatic uterine activity/threatened preterm labor and delivered within 7 days of diagnosis were excluded from the study. Records were analyzed for details on hospitalization, antenatal corticosteroid administration, cervical length measurements, and fetal/neonatal mortality and morbidity. RESULTS Of the 84 antenatally-diagnosed cases of vasa previa, 47 fulfilled eligibility criteria. A total of 15 cases were managed as OP, 22 as ASH and 10 as SH. Unplanned cesareans were highest in the SH arm (40% vs. 0% ASH vs. 13.3% OP). Those in the SH arm delivered earliest (median 33.8 weeks, interquartile range (IQR) 33.2-34.3 weeks). Of the asymptomatic patients, those in the ASH arm delivered earlier than those in the OP arm (35.3 [34.6-36.2] weeks vs. 36.7 [35.6-37.2] weeks, p = 0.037). There were no cases of fetal/neonatal death, anemia or severe neonatal morbidity and no significant differences between groups based on cervical length or antenatal corticosteroid administration. CONCLUSIONS Our study suggests that asymptomatic women with an antenatal diagnosis of vasa previa, singleton pregnancies, and at low risk for preterm birth may safely managed as outpatients, as long as they are able to access hospital promptly in the event of antepartum bleeding or early labor.
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Affiliation(s)
- Linda A. Villani
- Division of Maternal and Fetal Medicine, Department of Obstetrics & GynecologyMount Sinai Hospital, University of TorontoTorontoOntarioCanada
| | - Rashida Al‐Torshi
- Division of Maternal and Fetal Medicine, Department of Obstetrics & GynecologyMount Sinai Hospital, University of TorontoTorontoOntarioCanada
| | - Prakesh S. Shah
- Department of PediatricsMount Sinai Hospital, University of TorontoTorontoOntarioCanada
| | - John C. Kingdom
- Division of Maternal and Fetal Medicine, Department of Obstetrics & GynecologyMount Sinai Hospital, University of TorontoTorontoOntarioCanada
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics & GynecologyMount Sinai Hospital, University of TorontoTorontoOntarioCanada
- Department of Obstetrics & GynecologyMcMaster UniversityHamiltonOntarioCanada
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
| | - Johannes Keunen
- Division of Maternal and Fetal Medicine, Department of Obstetrics & GynecologyMount Sinai Hospital, University of TorontoTorontoOntarioCanada
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9
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Muraca GM, Ralph LE, Christensen P, D'Souza R, Geoffrion R, Lisonkova S, Joseph KS. Maternal and neonatal trauma during forceps and vacuum delivery must not be overlooked. BMJ 2023; 383:e073991. [PMID: 37857419 PMCID: PMC10585424 DOI: 10.1136/bmj-2022-073991] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Affiliation(s)
- Giulia M Muraca
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Sweden
| | | | - Penny Christensen
- Public representative, Birth Trauma Canada, Saint John, New Brunswick, Canada
| | - Rohan D'Souza
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Roxana Geoffrion
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Darling EK, Lemay SB, Ejiwunmi 'R, Miller KJ, Sprague AE, D'Souza R. The impact of funding models on the integration of Ontario midwives: a qualitative study. BMC Health Serv Res 2023; 23:1087. [PMID: 37821937 PMCID: PMC10568882 DOI: 10.1186/s12913-023-10104-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 10/03/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Nearly 30 years post legalisation and introduction, midwifery is still not optimally integrated within the health system of Canada's largest province, Ontario. Funding models have been identified as one of the main barriers. METHODS Using a constructivist perspective, we conducted a qualitative descriptive study to examine how antepartum, intrapartum, and postpartum funding arrangements in Ontario impact midwifery integration. We conceptualized optimal 'integration' as circumstances in which midwives' knowledge, skills, and model of care are broadly respected and fully utilized, interprofessional collaboration and referral support the best possible care for patients, and midwives feel a sense of belonging within hospitals and the greater health system. We collected data through semi-structured telephone interviews with midwives, obstetricians, family physicians, and nurses. The data was examined using thematic analysis. RESULTS We interviewed 20 participants, including 5 obstetricians, 5 family physicians, 5 midwives, 4 nurses, and 1 policy expert. We found that while course-of-care-based midwifery funding is perceived to support high levels of midwifery client satisfaction and excellent clinical outcomes, it lacks flexibility. This limits opportunities for interprofessional collaboration and for midwives to use their knowledge and skills to respond to health system gaps. The physician fee-for-service funding model creates competition for births, has unintended consequences that limit midwives' scope and access to hospital privileges, and fails to appropriately compensate physician consultants, particularly as midwifery volumes grow. Siloing of midwifery funding from hospital funding further restricts innovative contributions from midwives to respond to community healthcare needs. CONCLUSIONS Significant policy changes, such as adequate remuneration for consultants, possibly including salary-based physician funding; flexibility to compensate midwives for care beyond the existing course of care model; and a clearly articulated health human resource plan for sexual and reproductive care are needed to improve midwifery integration.
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Affiliation(s)
- Elizabeth K Darling
- McMaster Midwifery Research Centre, McMaster University, 1280 Main St. West, HSC-4H26, Hamilton, ON, L8S 4K1, Canada.
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada.
| | - Sylvie B Lemay
- McMaster Midwifery Research Centre, McMaster University, 1280 Main St. West, HSC-4H26, Hamilton, ON, L8S 4K1, Canada
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
| | - 'Remi Ejiwunmi
- McMaster Midwifery Research Centre, McMaster University, 1280 Main St. West, HSC-4H26, Hamilton, ON, L8S 4K1, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Katherine J Miller
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Ann E Sprague
- Better Outcomes Registry and Network (BORN) Ontario, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
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Pande SN, Yavana Suriya J, Ganapathy S, Pillai AA, Satheesh S, Mondal N, Harichandra Kumar KT, Silversides C, Siu SC, D'Souza R, Keepanasseril A. Validation of Risk Stratification for Cardiac Events in Pregnant Women With Valvular Heart Disease. J Am Coll Cardiol 2023; 82:1395-1406. [PMID: 37758434 DOI: 10.1016/j.jacc.2023.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/13/2023] [Accepted: 07/21/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Most risk stratification tools for pregnant patients with heart disease were developed in high-income countries and in populations with predominantly congenital heart disease, and therefore, may not be generalizable to those with valvular heart disease (VHD). OBJECTIVES The purpose of this study was to validate and establish the clinical utility of 2 risk stratification tools-DEVI (VHD-specific tool) and CARPREG-II-for predicting adverse cardiac events in pregnant patients with VHD. METHODS We conducted a cohort study involving consecutive pregnancies complicated with VHD admitted to a tertiary center in a middle-income setting from January 2019 to April 2022. Individual risk for adverse composite cardiac events was calculated using DEVI and CARPREG-II models. Performance was assessed through discrimination and calibration characteristics. Clinical utility was evaluated with Decision Curve Analysis. RESULTS Of 577 eligible pregnancies, 69 (12.1%) experienced a component of the composite outcome. A majority (94.7%) had rheumatic etiology, with mitral regurgitation as the predominant lesion (48.2%). The area under the receiver-operating characteristic curve was 0.884 (95% CI: 0.844-0.923) for the DEVI and 0.808 (95% CI: 0.753-0.863) for the CARPREG-II models. Calibration plots suggested that DEVI score overestimates risk at higher probabilities, whereas CARPREG-II score overestimates risk at both extremes and underestimates risk at middle probabilities. Decision curve analysis demonstrated that both models were useful across predicted probability thresholds between 10% and 50%. CONCLUSIONS In pregnant patients with VHD, DEVI and CARPREG-II scores showed good discriminative ability and clinical utility across a range of probabilities. The DEVI score showed better agreement between predicted probabilities and observed events.
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Affiliation(s)
- Swaraj Nandini Pande
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - J Yavana Suriya
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sachit Ganapathy
- Department of Biostatistics, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Ajith Ananthakrishna Pillai
- Department of Cardiology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Santhosh Satheesh
- Department of Cardiology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nivedita Mondal
- Department of Neonatology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - K T Harichandra Kumar
- Department of Biostatistics, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Candice Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada
| | - Samuel C Siu
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, University of Western Ontario, London, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Anish Keepanasseril
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India.
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12
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Humphries B, León-García M, Bates SM, Guyatt G, Eckman MH, D'Souza R, Shehata N, Jack SM, Alonso-Coello P, Xie F. Decision Analysis in SHared decision making for Thromboprophylaxis during Pregnancy (DASH-TOP): a sequential explanatory mixed-methods pilot study. BMJ Evid Based Med 2023; 28:309-319. [PMID: 36858800 DOI: 10.1136/bmjebm-2022-112098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2023] [Indexed: 03/03/2023]
Abstract
OBJECTIVES To gain insight into formal methods of integrating patient preferences and clinical evidence to inform treatment decisions, we explored patients' experience with a personalised decision analysis intervention, for prophylactic low-molecular-weight heparin (LMWH) in the antenatal period. DESIGN Mixed-methods explanatory sequential pilot study. SETTING Hospitals in Canada (n=1) and Spain (n=4 sites). Due to the COVID-19 pandemic, we conducted part of the study virtually. PARTICIPANTS 15 individuals with a prior venous thromboembolism who were pregnant or planning pregnancy and had been referred for counselling regarding LMWH. INTERVENTION A shared decision-making intervention that included three components: (1) direct choice exercise; (2) preference elicitation exercises and (3) personalised decision analysis. MAIN OUTCOME MEASURES Participants completed a self-administered questionnaire to evaluate decision quality (decisional conflict, self-efficacy and satisfaction). Semistructured interviews were then conducted to explore their experience and perceptions of the decision-making process. RESULTS Participants in the study appreciated the opportunity to use an evidence-based decision support tool that considered their personal values and preferences and reported feeling more prepared for their consultation. However, there were mixed reactions to the standard gamble and personalised treatment recommendation. Some participants could not understand how to complete the standard gamble exercises, and others highlighted the need for more informative ways of presenting results of the decision analysis. CONCLUSION Our results highlight the challenges and opportunities for those who wish to incorporate decision analysis to support shared decision-making for clinical decisions.
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Affiliation(s)
- Brittany Humphries
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Montserrat León-García
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - M H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rohan D'Souza
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nadine Shehata
- Departments of Medicine, Laboratory Medicine and Pathobiology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Susan M Jack
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
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13
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Young D, Houshmand B, Tan CC, Kirubarajan A, Parbhakar A, Dada J, Whittle W, Sobel ML, Gomez LM, Rüdiger M, Pecks U, Oppelt P, Ray JG, Hobson SR, Snelgrove JW, D'Souza R, Kashef R, Sussman D. Predicting adverse outcomes in pregnant patients positive for SARS-CoV-2: a machine learning approach- a retrospective cohort study. BMC Pregnancy Childbirth 2023; 23:553. [PMID: 37532986 PMCID: PMC10394879 DOI: 10.1186/s12884-023-05679-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 05/04/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Pregnant people are particularly vulnerable to SARS-CoV-2 infection and to ensuing severe illness. Predicting adverse maternal and perinatal outcomes could aid clinicians in deciding on hospital admission and early initiation of treatment in affected individuals, streamlining the triaging processes. METHODS An international repository of 1501 SARS-CoV-2-positive cases in pregnancy was created, consisting of demographic variables, patient comorbidities, laboratory markers, respiratory parameters, and COVID-19-related symptoms. Data were filtered, preprocessed, and feature selection methods were used to obtain the optimal feature subset for training a variety of machine learning models to predict maternal or fetal/neonatal death or critical illness. RESULTS The Random Forest model demonstrated the best performance among the trained models, correctly identifying 83.3% of the high-risk patients and 92.5% of the low-risk patients, with an overall accuracy of 89.0%, an AUC of 0.90 (95% Confidence Interval 0.83 to 0.95), and a recall, precision, and F1 score of 0.85, 0.94, and 0.89, respectively. This was achieved using a feature subset of 25 features containing patient characteristics, symptoms, clinical signs, and laboratory markers. These included maternal BMI, gravidity, parity, existence of pre-existing conditions, nicotine exposure, anti-hypertensive medication administration, fetal malformations, antenatal corticosteroid administration, presence of dyspnea, sore throat, fever, fatigue, duration of symptom phase, existence of COVID-19-related pneumonia, need for maternal oxygen administration, disease-related inpatient treatment, and lab markers including sFLT-1/PlGF ratio, platelet count, and LDH. CONCLUSIONS We present the first COVID-19 prognostication pipeline specifically for pregnant patients while utilizing a large SARS-CoV-2 in pregnancy data repository. Our model accurately identifies those at risk of severe illness or clinical deterioration, presenting a promising tool for advancing personalized medicine in pregnant patients with COVID-19.
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Affiliation(s)
- Dylan Young
- Department of Electrical, Computer and Biomedical Engineering, Toronto Metropolitan University (formerly Ryerson University), 350 Victoria St, Toronto, ON, M5B 0A1, Canada
- Institute for Biomedical Engineering, Science and Technology (iBEST), Toronto Metropolitan University & St. Michael's Hospital, Toronto, Canada
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | - Bita Houshmand
- Department of Electrical, Computer and Biomedical Engineering, Toronto Metropolitan University (formerly Ryerson University), 350 Victoria St, Toronto, ON, M5B 0A1, Canada
- Institute for Biomedical Engineering, Science and Technology (iBEST), Toronto Metropolitan University & St. Michael's Hospital, Toronto, Canada
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | - Chunyi Christie Tan
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Abirami Kirubarajan
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
| | - Ashna Parbhakar
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Jazleen Dada
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Wendy Whittle
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Canada
| | - Mara L Sobel
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Canada
| | - Luis M Gomez
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, INOVA Health System, Falls Church, VA, USA
| | - Mario Rüdiger
- Saxony Center for Feto-Neonatal Health, Medizinische Fakultät Der TU Dresden, Dresden, Germany
| | - Ulrich Pecks
- Department of Obstetrics and Gynaecology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Peter Oppelt
- Department for Gynecology, Obstetrics and Gynecological Endocrinology, Kepler University Hospital Linz, Johannes Kepler Universität Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Joel G Ray
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Obstetrics and Gynaecology, St, Michael's Hospital, Toronto, Canada
| | - Sebastian R Hobson
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Canada
| | - John W Snelgrove
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Canada
- Department of Obstetrics & Gynaecology and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
| | - Rasha Kashef
- Department of Electrical, Computer and Biomedical Engineering, Toronto Metropolitan University (formerly Ryerson University), 350 Victoria St, Toronto, ON, M5B 0A1, Canada
- Institute for Biomedical Engineering, Science and Technology (iBEST), Toronto Metropolitan University & St. Michael's Hospital, Toronto, Canada
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | - Dafna Sussman
- Department of Electrical, Computer and Biomedical Engineering, Toronto Metropolitan University (formerly Ryerson University), 350 Victoria St, Toronto, ON, M5B 0A1, Canada.
- Institute for Biomedical Engineering, Science and Technology (iBEST), Toronto Metropolitan University & St. Michael's Hospital, Toronto, Canada.
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada.
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, Canada.
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14
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Cusimano MC, Liu J, Azizi P, Zipursky J, Sajewycz K, Sussman J, Kishibe T, Wong E, Ferguson SE, D'Souza R, Baxter NN. Adverse Fetal Outcomes and Maternal Mortality Following Nonobstetric Abdominopelvic Surgery in Pregnancy: A Systematic Review and Meta-analysis. Ann Surg 2023; 278:e147-e157. [PMID: 34966066 DOI: 10.1097/sla.0000000000005362] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To quantify the absolute risks of adverse fetal outcomes and maternal mortality following nonobstetric abdominopelvic surgery in pregnancy. SUMMARY BACKGROUND DATA Surgery is often necessary in pregnancy, but absolute measures of risk required to guide perioperative management are lacking. METHODS We systematically searched MEDLINE, EMBASE, and EvidenceBased Medicine Reviews from January 1, 2000, to December 9, 2020, for observational studies and randomized trials of pregnant patients undergoing nonobstetric abdominopelvic surgery. We determined the pooled proportions of fetal loss, preterm birth, and maternal mortality using a generalized linear random/mixed effects model with a logit link. RESULTS We identified 114 observational studies (52 [46%] appendectomy, 34 [30%] adnexal, 8 [7%] cholecystectomy, 20 [17%] mixed types) reporting on 67,111 pregnant patients. Overall pooled proportions of fetal loss, preterm birth, and maternal mortality were 2.8% (95% CI 2.2-3.6), 9.7% (95% CI 8.3-11.4), and 0.04% (95% CI 0.02-0.09; 4/10,000), respectively. Rates of fetal loss and preterm birth were higher for pelvic inflammatory conditions (eg, appendectomy, adnexal torsion) than for abdominal or nonurgent conditions (eg, cholecystectomy, adnexal mass). Surgery in the second and third trimesters was associated with lower rates of fetal loss (0.1%) and higher rates of preterm birth (13.5%) than surgery in the first and second trimesters (fetal loss 2.9%, preterm birth 5.6%). CONCLUSIONS Absolute risks of adverse fetal outcomes after nonobstetric abdom- inopelvic surgery vary with gestational age, indication, and acuity. Pooled estimates derived here identify high-risk clinical scenarios, and can inform implementation of mitigation strategies and improve preoperative counselling.
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Affiliation(s)
- Maria C Cusimano
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School ofPublic Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Jessica Liu
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada
| | - Paymon Azizi
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School ofPublic Health, University of Toronto, Toronto, ON, Canada
| | - Jonathan Zipursky
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School ofPublic Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katrina Sajewycz
- School of Medicine, Faculty ofHealth Sciences, Queen's University, Kingston, ON, Canada
| | - Jess Sussman
- School of Medicine, Faculty ofMedicine, University of Toronto, Toronto, ON, Canada
| | - Teruko Kishibe
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Health Sciences Library, St. Michael's Hospital, Toronto, ON, Canada
| | - Eric Wong
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School ofPublic Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sarah E Ferguson
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/Sinai Health Systems, Toronto, ON, Canada
| | - Rohan D'Souza
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada
- Division of Maternal Fetal Medicine, Mount Sinai Hospital/Sinai Health Systems, Toronto, ON, Canada
| | - Nancy N Baxter
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School ofPublic Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne ViC, Australia
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15
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Bhatia K, D'Souza R, Malhamé I, Thorne S. Anaesthetic considerations in pregnant patients with cardiac arrhythmia. BJA Educ 2023; 23:196-206. [PMID: 37124169 PMCID: PMC10140473 DOI: 10.1016/j.bjae.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 01/27/2023] [Indexed: 03/06/2023] Open
Affiliation(s)
- K. Bhatia
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - R. D'Souza
- McMaster University, Hamilton, Ontario, Canada
| | - I. Malhamé
- McGill University Health Centre, Montreal, Quebec, Canada
| | - S. Thorne
- University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, Toronto, Ontario, Canada
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O'Rinn SE, Barrett JFR, Parsons JA, Kingdom JC, D'Souza R. Engaging pregnant individuals and healthcare professionals in an international mixed methods study to develop a core outcome set for studies on placenta accreta spectrum disorder (COPAS): a study protocol. BMJ Open 2023; 13:e060699. [PMID: 37185194 PMCID: PMC10151908 DOI: 10.1136/bmjopen-2021-060699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Placenta accreta spectrum (PAS) disorder is a life-threatening condition that may result in serious maternal complications, including mortality. The placenta which is pathologically adherent to the uterine wall, places individuals at high risk of major haemorrhage during the third stage of labour. Current research reports on PAS disorder outcomes have highly variable levels of information, which is therefore difficult for investigators to aggregate to inform practice. There is an urgent need to harmonise data collection in prospective studies to identify and implement best practices for management. One approach to standardise outcomes across any health area via the use of core outcome sets (COSs), which are consensus-derived standardised sets of outcomes that all studies for a particular condition should measure and report. This protocol outlines the steps for developing a COS for PAS disorder (COPAS). METHODS AND ANALYSIS This protocol outlines steps for the creation of COPAS. The first step, a systematic review, will identify all reported outcomes in the scientific literature. The second step will use qualitative one-on-one interviews to identify additional outcomes identified as important by patients and healthcare professionals that are not reported in the published literature. Outcomes from the first two steps will be combined to form an outcome inventory. This outcome inventory will inform the third step which is a Delphi survey that encourages agreement between patients and healthcare professionals on which outcomes are most important for inclusion in the COS. The fourth step, a consensus group meeting of representative participants, will finalise outcomes for inclusion in the PAS disorder COS. ETHICS AND DISSEMINATION This study has obtained Research Ethics Board approval from Sunnybrook Health Sciences Centre (#2338, #1488). We will aim to publish the study findings in an international peer-reviewed OBGYN journal. REGISTRATION DETAILS COMET Core Outcome Set Registration: https://www.comet-initiative.org/Studies/Details/1127. PROSPERO REGISTRATION NUMBER CRD42020173426.
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Affiliation(s)
- Susan E O'Rinn
- Outcomes & Evaluation, Institute of Health, Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- DAN Women & Babies Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Jon F R Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Janet A Parsons
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - John C Kingdom
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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17
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D'Souza R, Doyle O, Miller H, Pillai N, Angehrn Z, Li P, Ispas-Jouron S. Prediction of successful labor induction in persons with a low Bishop score using machine learning: Secondary analysis of two randomized controlled trials. Birth 2023; 50:234-243. [PMID: 36544398 DOI: 10.1111/birt.12691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/12/2022] [Accepted: 10/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The objective of this paper was to identify predictors of a vaginal birth in individuals with singleton pregnancies and a Bishop Score <4, following Induction of Labor (IoL) using dinoprostone vaginal insert (DVI). Secondarily, we sought to understand the association between oxytocin use for labor augmentation and IoL outcomes. METHODS We developed and internally validated a multivariate prediction model using machine learning (ML) applied to data from two Phase-III randomized controlled double-blind trials (NCT01127581, NCT00308711). The model was internally validated using 10-fold cross-validation. RESULTS This study included 1107 participants. Despite unfavorable cervical status and inclusion of high-risk pregnancies, 72% of participants had vaginal births. The model's area under receiver operating characteristic curve was 0.73. The following factors increased the chance of vaginal birth: being parous; being between 37 and 41 weeks of gestation; having a lower Body Mass Index; having a lower maternal age; having fewer maternal comorbidities; and having a higher Bishop score. Parity alone correctly predicted the outcome in ~50% of cases, at a ~10% false-negative rate. Participants whose labors progressed without requiring oxytocin had a higher probability of vaginal birth than those requiring oxytocin for either induction or augmentation (81% vs 70% vs 77%, respectively). DISCUSSION Even in high-risk pregnancies and with low Bishop scores, the use of DVI results in a high chance of vaginal birth. Parity is a critical predictor of success. The judicious use of oxytocin for labor induction or augmentation can increase the chance of vaginal birth. Our study validates the use of ML and predictive modeling for treatment response prediction when considering IoL.
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Affiliation(s)
- Rohan D'Souza
- Departments of Obstetrics & Gynaecology and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | | | - Hugh Miller
- Watching Over Mothers & Babies Foundation, Tuscon, Arizona, USA
| | | | | | - Philip Li
- Ferring International, Saint-Prex, Switzerland
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18
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Kittleson MM, DeFilippis EM, Bhagra CJ, Casale JP, Cauldwell M, Coscia LA, D'Souza R, Gaffney N, Gerovasili V, Ging P, Horsley K, Macera F, Mastrobattista JM, Paraskeva MA, Punnoose LR, Rasmusson KD, Reynaud Q, Ross HJ, Thakrar MV, Walsh MN. Reproductive health after thoracic transplantation: An ISHLT expert consensus statement. J Heart Lung Transplant 2023; 42:e1-e42. [PMID: 36528467 DOI: 10.1016/j.healun.2022.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - Catriona J Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, UK
| | - Jillian P Casale
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland
| | - Matthew Cauldwell
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Lisa A Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Gaffney
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Kristin Horsley
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Francesca Macera
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Joan M Mastrobattista
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine Houston, Texas
| | - Miranda A Paraskeva
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Lynn R Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Quitterie Reynaud
- Cystic Fibrosis Adult Referral Care Centre, Department of Internal Medicine, Hospices civils de Lyon, Pierre Bénite, France
| | - Heather J Ross
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Mitesh V Thakrar
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
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19
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Jorgensen SCJ, Hernandez A, Fell DB, Austin PC, D'Souza R, Guttmann A, Brown KA, Buchan SA, Gubbay JB, Nasreen S, Schwartz KL, Tadrous M, Wilson K, Kwong JC. Maternal mRNA covid-19 vaccination during pregnancy and delta or omicron infection or hospital admission in infants: test negative design study. BMJ 2023; 380:e074035. [PMID: 36754426 PMCID: PMC9903336 DOI: 10.1136/bmj-2022-074035] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
OBJECTIVE To estimate the effectiveness of maternal mRNA covid-19 vaccination during pregnancy against delta and omicron severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and hospital admission in infants. DESIGN Test negative design study. SETTING Community and hospital testing in Ontario, Canada. PARTICIPANTS Infants younger than six months of age, born between 7 May 2021 and 31 March 2022, who were tested for SARS-CoV-2 between 7 May 2021 and 5 September 2022. INTERVENTION Maternal mRNA covid-19 vaccination during pregnancy. MAIN OUTCOME MEASURES Laboratory confirmed delta or omicron infection or hospital admission of the infant. Multivariable logistic regression estimated vaccine effectiveness, with adjustments for clinical and sociodemographic characteristics associated with vaccination and infection. RESULTS 8809 infants met eligibility criteria, including 99 delta cases (4365 controls) and 1501 omicron cases (4847 controls). Infant vaccine effectiveness from two maternal doses was 95% (95% confidence interval 88% to 98%) against delta infection and 97% (73% to 100%) against infant hospital admission due to delta and 45% (37% to 53%) against omicron infection and 53% (39% to 64%) against hospital admission due to omicron. Vaccine effectiveness for three doses was 73% (61% to 80%) against omicron infection and 80% (64% to 89%) against hospital admission due to omicron. Vaccine effectiveness for two doses against infant omicron infection was highest with the second dose in the third trimester (53% (42% to 62%)) compared with the first (47% (31% to 59%)) or second (37% (24% to 47%)) trimesters. Vaccine effectiveness for two doses against infant omicron infection decreased from 57% (44% to 66%) between birth and eight weeks to 40% (21% to 54%) after 16 weeks of age. CONCLUSIONS Maternal covid-19 vaccination with a second dose during pregnancy was highly effective against delta and moderately effective against omicron infection and hospital admission in infants during the first six months of life. A third vaccine dose bolstered protection against omicron. Effectiveness for two doses was highest with maternal vaccination in the third trimester, and effectiveness decreased in infants beyond eight weeks of age.
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Affiliation(s)
- Sarah C J Jorgensen
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Deshayne B Fell
- ICES, Toronto, ON, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Peter C Austin
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Rohan D'Souza
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- School of Graduate Studies, University of Toronto, Toronto, ON, Canada
| | - Astrid Guttmann
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
- The Edwin SH Leong Centre for Healthy Children, University of Toronto, Toronto, ON, Canada
| | - Kevin A Brown
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
| | - Sarah A Buchan
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre for Vaccine Preventable Diseases, University of Toronto, Toronto, ON, Canada
| | - Jonathan B Gubbay
- Public Health Ontario, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Sharifa Nasreen
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Kevin L Schwartz
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
| | - Mina Tadrous
- ICES, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Kumanan Wilson
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jeffrey C Kwong
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre for Vaccine Preventable Diseases, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
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20
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Feigin G, Velasco Figueroa S, Englesakis MF, D'Souza R, Hoydonckx Y, Bhatia A. Stellate Ganglion Block for Non-Pain Indications: A Scoping Review. Pain Med 2023:7023960. [PMID: 36727500 DOI: 10.1093/pm/pnad011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/26/2023] [Accepted: 01/31/2023] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Stellate ganglion block (SGB) is performed to relieve head, face, neck, or upper limb pain, several non-pain indications for performing this block have emerged over the years. To date, there was no attempt to synthesize evidence on SGB for treating non-pain indications. This scoping review presents a summary of the efficacy and adverse effects of SGB when performed for six non-pain indications. METHODS This scoping review was accomplished using Arksey and O'Malley framework. Literature search was conducted for relevant articles in medical databases to identify publications on SGB and specified study types. Two reviewers independently assessed the risk of bias for randomized controlled trials (RCTs), non-randomized comparative studies, and case series. Results were summarized and recommendations were made based on the strength of available evidence using the US Preventative Services Task Force grading system. RESULTS Twenty-four studies (19 RCTs and 5 non-randomized studies) were included in this review. Based on the evidence, SGB is recommended for obtunding cardiovascular sympathetic stimulation, improving perfusion in limbs, and alleviating menopausal symptoms with a Grade B or C recommendation and a moderate-to-low level of certainty. There was insufficient evidence to recommend SGB for the other indications. CONCLUSIONS SGB can be considered for obtunding cardiovascular sympathetic stimulation and stress response, reducing vascular tone to improve vascular insufficiency in the limbs and perioperative hemodynamic stability, and alleviating hot flashes in menopause, in conditions refractory to conventional medical management.
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Affiliation(s)
- Guy Feigin
- Department of Anesthesia and Pain Medicine, University of Toronto, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Sofia Velasco Figueroa
- Department of Anesthesia and Pain Medicine, University of Toronto, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Marina F Englesakis
- Library & Information Services, University Health Network, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics & Gynaecology and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario Canada; Department of Obstetrics and Gynaecology and Lunenfeld Tanenbaum Research Institute, Ontario, Canada
| | - Yasmine Hoydonckx
- Department of Anesthesia and Pain Medicine, University of Toronto, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Anuj Bhatia
- Department of Anesthesia and Pain Medicine, University of Toronto, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
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21
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Javinani A, Heydari MH, Khalil A, Landon MB, Berghella V, D'Souza R, Mustafa HJ. Rising trends in perinatal morbidity following trial of labor after cesarean delivery: population-based study. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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22
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Malhamé I, Dong S, Syeda A, Ashraf R, Zipursky J, Horn D, Daskalopoulou SS, D'Souza R. The use of loop diuretics in the context of hypertensive disorders of pregnancy: a systematic review and meta-analysis. J Hypertens 2023; 41:17-26. [PMID: 36453652 DOI: 10.1097/hjh.0000000000003310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
AIMS Addressing volume expansion may improve the management of hypertension across the pregnancy continuum. We conducted a systematic review to summarize the evidence on the use of loop diuretics in the context of hypertensive disorders during pregnancy and the postpartum period. METHODS AND RESULTS Medline, Embase, Cochrane library, ClinicalTrials.gov, and Google Scholar were searched for original research articles published up to 29 June 2021. Of the 2801 results screened, 15 studies were included: eight randomized controlled trials, six before-after studies, and one cohort study. Based on random effects meta-analysis of before-after studies, antepartum use of loop diuretics was associated with lower DBP [mean difference -17.73 mmHg, (95% confidence intervals -34.50 to -0.96); I2 = 94%] and lower cardiac output [mean difference -0.75 l/min, (-1.11 to -0.39); I2 = 0%], with no difference in SBP, mean arterial pressure, heart rate, or total peripheral resistance. Meta-analysis of randomized controlled trials revealed that postpartum use of loop diuretics was associated with decreased need for additional antihypertensive patients [relative risk 0.69, (0.50-0.97); I2 = 14%], and an increased duration of hospitalization [mean difference 8.80 h, (4.46-13.14); I2 = 83%], with no difference in the need for antihypertensive therapy at hospital discharge, or persistent postpartum hypertension. CONCLUSION Antepartum use of loop diuretics lowered DBP and cardiac output, while their postpartum use reduced the need for additional antihypertensive medications. There was insufficient evidence to suggest a clear benefit. Future studies focusing on women with hypertensive pregnancy disorders who may most likely benefit from loop diuretics are required.
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Affiliation(s)
- Isabelle Malhamé
- Department of Medicine, McGill University Health Centre
- Research Institute of the McGill University Health Centre, Montréal, Quebéc
| | - Susan Dong
- Faculty of Medicine, University of Toronto
| | - Ambreen Syeda
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto
| | - Rizwana Ashraf
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto
- Department of Obstetrics & Gynaecology, McMaster University, Hamilton
| | - Jonathan Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto
- Institute of Health Policy, Management, and Evaluation, University of Toronto
| | - Daphne Horn
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Stella S Daskalopoulou
- Department of Medicine, McGill University Health Centre
- Research Institute of the McGill University Health Centre, Montréal, Quebéc
| | - Rohan D'Souza
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto
- Department of Obstetrics & Gynaecology, McMaster University, Hamilton
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23
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D'Souza R, Yeretsian T, Javid N, Donnolley N, Ashraf R, Adams A, Kingdom JC. A core outcome set for studies on vasa previa (COVasP): an international consensus study. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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24
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Resende MHF, Yarnell CJ, D'Souza R, Lapinsky SE, Nam A, Shah V, Whittle W, Wright JK, Naimark DMJ. Clinical decision analysis of elective delivery vs expectant management for pregnant individuals with COVID-19-related acute respiratory distress syndrome. Am J Obstet Gynecol MFM 2022; 4:100697. [PMID: 35878805 PMCID: PMC9307282 DOI: 10.1016/j.ajogmf.2022.100697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pregnant individuals are vulnerable to COVID-19-related acute respiratory distress syndrome. There is a lack of high-quality evidence on whether elective delivery or expectant management leads to better maternal and neonatal outcomes. OBJECTIVE This study aimed to determine whether elective delivery or expectant management are associated with higher quality-adjusted life expectancy for pregnant individuals with COVID-19-related acute respiratory distress syndrome and their neonates. STUDY DESIGN We performed a clinical decision analysis using a patient-level model in which we simulatedpregnant individuals and their unborn children. We used a patient-level model with parallel open-cohort structure, daily cycle length, continuous discounting, lifetime horizon, sensitivity analyses for key parameter values, and 1000 iterations for quantification of uncertainty. We simulated pregnant individuals at 32 weeks of gestation, invasively ventilated because of COVID-19-related acute respiratory distress syndrome. In the elective delivery strategy, pregnant individuals received immediate cesarean delivery. In the expectant management strategy, pregnancies continued until spontaneous labor or obstetrical decision to deliver. For both pregnant individuals and neonates, model outputs were hospital or perinatal survival, life expectancy, and quality-adjusted life expectancy denominated in years, summarized by the mean and 95% credible interval. Maternal utilities incorporated neonatal outcomes in accordance with best practices in perinatal decision analysis. RESULTS Model outputs for pregnant individuals were similar when comparing elective delivery at 32 weeks' gestation with expectant management, including hospital survival (87.1% vs 87.4%), life-years (difference, -0.1; 95% credible interval, -1.4 to 1.1), and quality-adjusted life expectancy denominated in years (difference, -0.1; 95% credible interval, -1.3 to 1.1). For neonates, elective delivery at 32 weeks' gestation was estimated to lead to a higher perinatal survival (98.4% vs 93.2%; difference, 5.2%; 95% credible interval, 3.5-7), similar life-years (difference, 0.9; 95% credible interval, -0.9 to 2.8), and higher quality-adjusted life expectancy denominated in years (difference, 1.3; 95% credible interval, 0.4-2.2). For pregnant individuals, elective delivery was not superior to expectant management across a range of scenarios between 28 and 34 weeks of gestation. Elective delivery in cases where intrauterine death or maternal mortality were more likely resulted in higher neonatal quality-adjusted life expectancy, as did elective delivery at 30 weeks' gestation (difference, 1.1 years; 95% credible interval, 0.1 - 2.1) despite higher long-term complications (4.3% vs 0.5%; difference, 3.7%; 95% credible interval, 2.4-5.1), and in cases where intrauterine death or maternal acute respiratory distress syndrome mortality were more likely. CONCLUSION The decision to pursue elective delivery vs expectant management in pregnant individuals with COVID-19-related acute respiratory distress syndrome should be guided by gestational age, risk of intrauterine death, and maternal acute respiratory distress syndrome severity. For the pregnant individual, elective delivery is comparable but not superior to expectant management for gestational ages from 28 to 34 weeks. For neonates, elective delivery was superior if gestational age was ≥30 weeks and if the rate of intrauterine death or maternal mortality risk were high. We recommend basing the decision for elective delivery vs expectant management in a pregnant individual with COVID-19-related acute respiratory distress syndrome on gestational age and likelihood of intrauterine or maternal death.
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Affiliation(s)
- Maura H Ferrari Resende
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada (Drs Ferrari Resende, Yarnell, Shah, and Naimark); Sunnybrook Health Sciences Centre, Toronto, Canada (Drs Ferrari Resende and Naimark)
| | - Christopher J Yarnell
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada (Drs Ferrari Resende, Yarnell, Shah, and Naimark); Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada (Dr Yarnell and Dr Lapinsky); Department of Critical Care Medicine, Sinai Health System and the University Health Network, Toronto, Canada (Dr Yarnell and Dr Lapinsky).
| | - Rohan D'Souza
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada (Dr D'Souza); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sinai Health System, University of Toronto, Toronto, Canada (Drs D'Souza and Whittle)
| | - Stephen E Lapinsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada (Dr Yarnell and Dr Lapinsky); Department of Critical Care Medicine, Sinai Health System and the University Health Network, Toronto, Canada (Dr Yarnell and Dr Lapinsky); Department of Medicine, University of Toronto, Toronto, Canada (Dr Lapinsky and Drs Wright and Naimark)
| | | | - Vibhuti Shah
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada (Drs Ferrari Resende, Yarnell, Shah, and Naimark); Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada (Dr Shah)
| | - Wendy Whittle
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sinai Health System, University of Toronto, Toronto, Canada (Drs D'Souza and Whittle)
| | - Julie K Wright
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada (Dr Wright); Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada (Dr Wright); Department of Medicine, University of Toronto, Toronto, Canada (Dr Lapinsky and Drs Wright and Naimark)
| | - David M J Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada (Drs Ferrari Resende, Yarnell, Shah, and Naimark); Sunnybrook Health Sciences Centre, Toronto, Canada (Drs Ferrari Resende and Naimark); Department of Medicine, University of Toronto, Toronto, Canada (Dr Lapinsky and Drs Wright and Naimark)
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25
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Javid N, Donnolley N, Dadouch MR, Kingdom J, D'Souza R. Identifying outcomes for vasa praevia that are important for women: a qualitative study to inform a Core Outcome Set. Women Birth 2022. [DOI: 10.1016/j.wombi.2022.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Gédéon T, Akl E, D'Souza R, Altit G, Rowe H, Flannery A, Siriki P, Bhatia K, Thorne S, Malhamé I. Acute Myocardial Infarction in Pregnancy. Curr Probl Cardiol 2022; 47:101327. [PMID: 35901856 DOI: 10.1016/j.cpcardiol.2022.101327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/17/2022] [Indexed: 11/03/2022]
Abstract
Cardiovascular disease, and particularly ischemic heart disease, is a leading cause of maternal morbidity and mortality in high-income countries. The incidence of acute myocardial infarction (AMI) has been rising over the past two decades due to increasing maternal age and a higher prevalence of cardiovascular risk factors in the pregnant population. Causes of AMI in pregnancy are diverse and may require specific considerations for their diagnosis and management. In this narrative review, we provide an overview of physiologic changes, risk factors, and etiologies leading to AMI in pregnancy, as well as diagnostic tools, reperfusion strategies, and pharmacological treatments for this complex population. In addition, we outline considerations for labor and delivery planning and long-term follow-up of patients with AMI in pregnancy.
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Affiliation(s)
- Tara Gédéon
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Elie Akl
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Gabriel Altit
- Department of Paediatrics, McGill University Health Centre, Montreal, Canada
| | - Hilary Rowe
- Department of Pharmacy, Nanaimo Regional General Hospital, Island Health, Nanaimo, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Alexandria Flannery
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | | | - Kailash Bhatia
- Department of Anaesthesia, Manchester University Hospitals and St Mary's Hospital, University of Manchester, Manchester, United Kingdom
| | - Sara Thorne
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montreal, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada.
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Wichert-Schmitt B, D'Souza R, Silversides CK. Reproductive Issues in Patients With the Fontan Operation. Can J Cardiol 2022; 38:921-929. [PMID: 35490924 DOI: 10.1016/j.cjca.2022.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 01/09/2023] Open
Abstract
Patients with the Fontan operation have a unique circulation, with a limited ability to increase cardiac output, and high central venous pressure. They may have diastolic and/or systolic ventricular dysfunction, arrhythmias, thromboembolic complications, or multiorgan dysfunction. All of these factors contribute to reproductive issues, including menstrual irregularities, infertility, recurrent miscarriage, and complications during pregnancy. Although atrial arrhythmias are the most common cardiac complications during pregnancy, patients can develop heart failure and thromboembolic events. Obstetric bleeding, including postpartum hemorrhage, is common. In addition to maternal complications, adverse fetal and neonatal events, such as prematurity and low birthweight, are very common. Counselling about these reproductive issues should begin early. For those who become pregnant, care should be provided by a multidisciplinary cardio-obstetric team familiar with the specific issues and needs of the Fontan population. In this review, we discuss infertility, contraception, and pregnancy in patients with the Fontan operation.
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Affiliation(s)
- Barbara Wichert-Schmitt
- Department of Cardiology and Medical Intensive Care, Kepler University Hospital, Medical Faculty, Johannes Kepler University, Linz, Austria.
| | - Rohan D'Souza
- Departments of Obstetrics & Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Candice K Silversides
- Division of Cardiology, University of Toronto, Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, Toronto, Ontario, Canada
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Taylor T, Simpson AN, D'Souza R. Avoiding the echo-chamber: embracing qualitative research in obstetrics and gynecology to amplify patient voices. Acta Obstet Gynecol Scand 2022; 101:702-704. [PMID: 35510937 DOI: 10.1111/aogs.14346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/19/2022] [Accepted: 02/22/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Taryn Taylor
- Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada.,Center for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Andrea N Simpson
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Obstetrics and Gynecology, St. Michael's Hospital/Unity Health Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynecology and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Obstetrics and Gynecology and the Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Richards M, Huang M, Strickland MJ, Newman AJ, Warren JL, D'Souza R, Chang HH, Darrow LA. Acute association between heatwaves and stillbirth in six US states. Environ Health 2022; 21:59. [PMID: 35710419 PMCID: PMC9202158 DOI: 10.1186/s12940-022-00870-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Heatwaves are becoming more frequent and may acutely increase the risk of stillbirth, a rare and severe pregnancy outcome. OBJECTIVES Examine the association between multiple heatwave metrics and stillbirth in six U.S. states. METHODS Data were collected from fetal death and birth records in California (1996-2017), Florida (1991-2017), Georgia (1994-2017), Kansas (1991-2017), New Jersey (1991-2015), and Oregon (1991-2017). Cases were matched to controls 1:4 based on maternal race/ethnicity, maternal education, and county, and exposure windows were aligned (gestational week prior to stillbirth). County-level temperature data were obtained from Daymet and linked to cases and controls by residential county and the exposure window. Five heatwave metrics (1 categorical, 3 dichotomous, 1 continuous) were created using different combinations of the duration and intensity of hot days (mean daily temperature exceeding the county-specific 97.5th percentile) during the exposure window, as well as a continuous measure of mean temperature during the exposure window modeled using natural splines to allow for nonlinear associations. State-specific odds ratios (ORs) and 95% confidence intervals (CI) were estimated using conditional logistic regression models. State-specific results were pooled using a fixed-effects meta-analysis. RESULTS In our data set of 140,428 stillbirths (553,928 live birth controls), three of the five heatwave metrics examined were not associated with stillbirth. However, four consecutive hot days during the previous week was associated with a 3% increase in stillbirth risk (CI: 1.01, 1.06), and a 1 °C average increase over the threshold was associated with a 10% increase in stillbirth risk (CI: 1.04, 1.17). In continuous temperature analyses, there was a slight increased risk of stillbirth associated with extremely hot temperatures (≥ 35 °C). DISCUSSION Most heat wave definitions examined were not associated with acute changes in stillbirth risk; however, the most extreme heatwave durations and temperatures were associated with a modest increase in stillbirth risk.
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Affiliation(s)
- Megan Richards
- School of Public Health, University of Nevada, 1664 N Virginia St, m/s 0275, NV, 89557, Reno, USA.
| | - Mengjiao Huang
- School of Public Health, University of Nevada, 1664 N Virginia St, m/s 0275, NV, 89557, Reno, USA
| | - Matthew J Strickland
- School of Public Health, University of Nevada, 1664 N Virginia St, m/s 0275, NV, 89557, Reno, USA
| | | | - Joshua L Warren
- Department of Biostatistics, Yale University, New Haven, CT, USA
| | - Rohan D'Souza
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Howard H Chang
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lyndsey A Darrow
- School of Public Health, University of Nevada, 1664 N Virginia St, m/s 0275, NV, 89557, Reno, USA
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Malhamé I, Knight M, D'Souza R. Initial Steps in Developing and Implementing a Canadian Obstetric Survey System (CanOSS) for Severe Maternal Morbidity. J Obstet Gynaecol Can 2022; 44:637-638. [PMID: 35691680 DOI: 10.1016/j.jogc.2022.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/08/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montréal, QC; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, QC.
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rohan D'Souza
- Departments of Obstetrics & Gynaecology and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON
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Malhamé I, Knight M, D'Souza R. Prémices de la conception et mise en œuvre d'un système d'enquête canadien en obstétrique sur la morbidité maternelle grave. J Obstet Gynaecol Can 2022; 44:639-640. [PMID: 35691681 DOI: 10.1016/j.jogc.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Isabelle Malhamé
- Département de médecine, Centre universitaire de santé McGill, Université McGill, Montréal, Qc; Centre de recherche évaluative en santé, Institut de recherche du Centre universitaire de santé McGill, Montréal, Qc
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Université d'Oxford, Oxford, R.-U
| | - Rohan D'Souza
- Département d'obstétrique et gynécologie et Département des méthodes de recherche en santé, des données probantes et de l'impact, Université McMaster, Hamilton, Ont
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Ashwal E, Chen W, Doleeb Z, Alshamsi N, Lau C, Tesfaye M, D'Souza R, Maxwell C. Induction of Labour in Women with Class III Obesity (Body Mass Index ≥40 kg/m2)—Maternal and Neonatal Outcomes. Journal of Obstetrics and Gynaecology Canada 2022. [DOI: 10.1016/j.jogc.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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D'Souza R, Seymour RJ, Knight M, Dzakpasu S, Joseph KS, Thorne S, Ospina MB, Barrett J, Cook J, Fell DB, Scott H, Metcalfe A, van den Akker T, Lapinsky S, Skeith L, Murray-Davis B, Shah P, Forte M, Ashraf R, Chundamala J, Hutchinson SA, Chen KK, Malhamé I. Feasibility of establishing a Canadian Obstetric Survey System (CanOSS) for severe maternal morbidity: a study protocol. BMJ Open 2022; 12:e061093. [PMID: 35321901 PMCID: PMC8943762 DOI: 10.1136/bmjopen-2022-061093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Severe maternal morbidity (SMM)-an unexpected pregnancy-associated maternal outcome resulting in severe illness, prolonged hospitalisation or long-term disability-is recognised by many, as the preferred indicator of the quality of maternity care, especially in high-income countries. Obtaining comprehensive details on events and circumstances leading to SMM, obtained through maternity units, could complement data from large epidemiological studies and enable targeted interventions to improve maternal health. The aim of this study is to assess the feasibility of gathering such data from maternity units across Canadian provinces and territories, with the goal of establishing a national obstetric survey system for SMM in Canada. METHODS AND ANALYSIS We propose a sequential explanatory mixed-methods study. We will first distribute a cross-sectional survey to leads of all maternity units across Canada to gather information on (1) Whether the unit has a system for reviewing SMM and the nature and format of this system, (2) Willingness to share anonymised data on SMM by direct entry using a web-based platform and (3) Respondents' perception on the definition and leading causes of SMM at a local level. This will be followed by semistructured interviews with respondent groups defined a priori, to identify barriers and facilitators for data sharing. We will perform an integrated analysis to determine feasibility outcomes, a narrative description of barriers and facilitators for data-sharing and resource implications for data acquisition on an annual basis, and variations in top-5 causes of SMM. ETHICS AND DISSEMINATION The study has been approved by the Mount Sinai and Hamilton Integrated Research Ethics Boards. The study findings will be presented at annual scientific meetings of the Society of Obstetricians and Gynaecologists of Canada, North American Society of Obstetric Medicine, and International Network of Obstetric Survey Systems and published in an open-access peer-reviewed Obstetrics and Gynaecology or General Internal Medicine journal.
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Affiliation(s)
- Rohan D'Souza
- Department of Obstetrics & Gynaecology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics & Gynaecology, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca J Seymour
- Department of Obstetrics & Gynaecology, McMaster University, Hamilton, Ontario, Canada
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Susie Dzakpasu
- Maternal and Infant Health Section, Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - K S Joseph
- Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, British Columbia, Canada
- The University of British Columbia School of Population and Public Health, Vancouver, British Columbia, Canada
| | - Sara Thorne
- Division of Cardiology, Pregnancy & Heart Disease Program, University of Toronto, Toronto, Ontario, Canada
| | - Maria B Ospina
- Department of Obstetrics & Gynecology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jon Barrett
- Department of Obstetrics & Gynaecology, McMaster University, Hamilton, Ontario, Canada
| | - Jocelynn Cook
- Society of Obstetricians and Gynaecologists, Ottawa, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Deshayne B Fell
- School of Epidemiology and Public Health, Children's Hospital of Eastern Ontario (CHEO) Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Heather Scott
- Department of Obstetrics & Gynaecology, Dalhousie University and the IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Amy Metcalfe
- Department of Community Health Sciences, Department of Obstetrics & Gynaecology, and Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Thomas van den Akker
- Department of Obstetrics & Gynaecology, Leiden University, Leiden, The Netherlands
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
| | - Stephen Lapinsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Leslie Skeith
- Division of Hematology and Hematological Malignancies, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Beth Murray-Davis
- McMaster Midwifery Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Prakesh Shah
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Milena Forte
- Department of Family and Community Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Rizwana Ashraf
- Department of Obstetrics & Gynaecology, McMaster University, Hamilton, Ontario, Canada
| | - Josie Chundamala
- Department of Obstetrics & Gynaecology, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sarah A Hutchinson
- Department of Obstetrics & Gynaecology, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kenneth K Chen
- Departments of Medicine and Obstetrics & Gynecology, Women and Infants Hospital of Rhode Island, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Isabelle Malhamé
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Yang J, D'Souza R, Kharrat A, Fell DB, Snelgrove JW, Shah PS. COVID-19 pandemic and population-level pregnancy and neonatal outcomes in general population: A living systematic review and meta-analysis (Update#2: November 20, 2021). Acta Obstet Gynecol Scand 2022; 101:273-292. [PMID: 35088409 DOI: 10.1111/aogs.14318] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 12/30/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Conflicting reports of increases and decreases in rates of preterm birth (PTB) and stillbirth in the general population during the coronavirus disease 2019 (COVID-19) pandemic have surfaced. The objective of our study was to conduct a living systematic review and meta-analyses of studies reporting pregnancy and neonatal outcomes by comparing the pandemic and pre-pandemic periods. MATERIAL AND METHODS We searched the PubMed and Embase databases and reference lists of articles published up until November 20, 2021, and included English language studies that compared outcomes between the COVID-19 pandemic time period with pre-pandemic time periods. Risk of bias was assessed using the Newcastle-Ottawa scale. We conducted random-effects meta-analysis using the inverse variance method. RESULTS Fifty-two studies with low-to-moderate risk of bias, reporting on 2 372 521 pregnancies during the pandemic period and 28 518 300 pregnancies during the pre-pandemic period, were included. There was significant reduction in unadjusted estimates of PTB (43 studies, unadjusted odds ratio [uaOR] 0.95, 95% CI 0.93-0.98), but not in adjusted estimates (five studies, adjusted OR [aOR] 0.94, 95% CI 0.74-1.19). This reduction was noted in studies from single centers/health areas (29 studies, uaOR 0.90, 95% CI 0.85-0.94) but not in regional/national studies (14 studies, uaOR 0.99, 95% CI 0.99-1.01). There was reduction in spontaneous PTB (nine studies, uaOR 0.91, 95% CI 0.88-0.94) but not in induced PTB (eight studies, uaOR 0.90, 95% CI 0.79-1.01). There was no difference in the odds of stillbirth between the pandemic and pre-pandemic time periods (32 studies, uaOR 1.07, 95% CI 0.97-1.18 and three studies, aOR 1.18, 95% CI 0.86-1.63). There was an increase in mean birthweight during the pandemic period compared with the pre-pandemic period (nine studies, mean difference 21 g, 95% CI 13-30 g). The odds of maternal mortality were increased (five studies, uaOR 1.15, 95% CI 1.05-1.26); however, only unadjusted estimates were available, and the result was mostly influenced by one study from Mexico. There was significant publication bias for the outcome of PTB. CONCLUSIONS The COVID-19 pandemic may be associated with a reduction in PTB; however, referral bias cannot be excluded. There was no statistically significant difference in stillbirths between pandemic and pre-pandemic periods.
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Affiliation(s)
- Jie Yang
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ashraf Kharrat
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Deshayne B Fell
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - John W Snelgrove
- Department of Obstetrics and Gynaecology and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Prakesh S Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada.,Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Bhatia K, Shehata N, D'Souza R. Anaesthetic considerations and anticoagulation in pregnant patients with mechanical heart valves. BJA Educ 2022; 22:273-281. [DOI: 10.1016/j.bjae.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Gold S, Clarfield L, Johnstone J, Diambomba Y, Shah PS, Whittle W, Abbasi N, Arzola C, Ashraf R, Biringer A, Chitayat D, Czikk M, Forte M, Franklin T, Jacobson M, Keunen J, Kingdom J, Lapinsky S, MacKenzie J, Maxwell C, Preisman M, Ryan G, Selk A, Sermer M, Silversides C, Snelgrove J, Watts N, Young B, De Castro C, D'Souza R. Adapting obstetric and neonatal services during the COVID-19 pandemic: a scoping review. BMC Pregnancy Childbirth 2022; 22:119. [PMID: 35148698 PMCID: PMC8840792 DOI: 10.1186/s12884-022-04409-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 01/18/2022] [Indexed: 12/02/2022] Open
Abstract
Background The provision of care to pregnant persons and neonates must continue through pandemics. To maintain quality of care, while minimizing physical contact during the Severe Acute Respiratory Syndrome-related Coronavirus-2 (SARS-CoV2) pandemic, hospitals and international organizations issued recommendations on maternity and neonatal care delivery and restructuring of clinical and academic services. Early in the pandemic, recommendations relied on expert opinion, and offered a one-size-fits-all set of guidelines. Our aim was to examine these recommendations and provide the rationale and context to guide clinicians, administrators, educators, and researchers, on how to adapt maternity and neonatal services during the pandemic, regardless of jurisdiction. Method Our initial database search used Medical subject headings and free-text search terms related to coronavirus infections, pregnancy and neonatology, and summarized relevant recommendations from international society guidelines. Subsequent targeted searches to December 30, 2020, included relevant publications in general medical and obstetric journals, and updated society recommendations. Results We identified 846 titles and abstracts, of which 105 English-language publications fulfilled eligibility criteria and were included in our study. A multidisciplinary team representing clinicians from various disciplines, academics, administrators and training program directors critically appraised the literature to collate recommendations by multiple jurisdictions, including a quaternary care Canadian hospital, to provide context and rationale for viable options. Interpretation There are different schools of thought regarding effective practices in obstetric and neonatal services. Our critical review presents the rationale to effectively modify services, based on the phase of the pandemic, the prevalence of infection in the population, and resource availability. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04409-4.
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Affiliation(s)
- Shira Gold
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | | | - Jennie Johnstone
- Department of Laboratory Medicine and Pathobiology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Yenge Diambomba
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - Prakesh S Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - Wendy Whittle
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - Nimrah Abbasi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - Cristian Arzola
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rizwana Ashraf
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - Anne Biringer
- Department of Family Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - David Chitayat
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - Marie Czikk
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - Milena Forte
- Department of Family Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Tracy Franklin
- Department of Family and Community Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Michelle Jacobson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - Johannes Keunen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - John Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | | | - Joanne MacKenzie
- Department of Nursing, Mount Sinai Hospital, Toronto, ON, Canada
| | - Cynthia Maxwell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - Mary Preisman
- Department of Psychiatry, Mount Sinai Hospital, Toronto, ON, Canada
| | - Greg Ryan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - Amanda Selk
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - Mathew Sermer
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - Candice Silversides
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - John Snelgrove
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - Nancy Watts
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada
| | - Beverly Young
- Department of Psychiatry, Mount Sinai Hospital, Toronto, ON, Canada
| | | | - Rohan D'Souza
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Room 3-908, Toronto, ON, M5G 1X5, Canada.
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Howard DC, Jones MAE, Skeith A, Lai J, D'Souza R, Caughey AB. Tranexamic Acid for the Treatment of Postpartum Hemorrhage: A Cost-Effectiveness Analysis. Am J Obstet Gynecol MFM 2022; 4:100588. [PMID: 35124299 DOI: 10.1016/j.ajogmf.2022.100588] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/29/2022] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is a leading cause of pregnancy-related morbidity and mortality. Recent data has demonstrated that tranexamic acid (TXA) reduces death due to bleeding when used as a treatment for PPH. The World Health Organization (WHO) now recommends TXA as a first-line treatment for PPH, however data is not yet available on the frequency of use in the United States, where TXA is currently recognized as an adjunct treatment for PPH. OBJECTIVE We aimed to strengthen the current evidence that TXA should be recognized as a first-line treatment for PPH, even in high-resource countries. Furthermore, we aimed to determine whether early administration of TXA (within 3 hours of diagnosis) is a cost-effective strategy for reducing maternal morbidity and mortality from PPH in the United States. STUDY DESIGN A decision analytic model was designed in order to compare the outcomes and costs of TXA use in the treatment of PPH. This model was then used to compare outcomes for early administration with those of routine use. The interventions compared were 1 gram of intravenous TXA or matching placebo. The risks analyzed in the model were death due to hemorrhage and laparotomy to control bleeding. Probabilities, utilities, and costs were derived from literature. Quality-adjusted life years (QALYs) were calculated using a discounted life expectancy rate of 3 percent. Cost-effectiveness was determined based on a willingness-to-pay threshold of $100,000 per QALY. RESULTS Administration of TXA to theoretical cohort of 100,000 women would prevent 11 maternal deaths, 6 postpartum laparotomies after vaginal delivery, and 112 re-operations after cesarean delivery. This would lead to an increase in 329 QALYs and a total cost savings of 15.39 million. Furthermore, if TXA were administered early (within 3 hours of PPH diagnosis) to the same theoretical cohort, 16 maternal deaths due to hemorrhage, 9 laparotomies, and 155 re-operations would be prevented. This amounts to an increase in 438 QALYs and an annual cost savings of $23.15 million. Sensitivity analysis showed that the administration of TXA was the dominant strategy at all probabilities of maternal death due to hemorrhage greater than 0.00002. When the cost of TXA was varied, TXA use remained dominant up to a cost of $267 per administration in the US if given within the first 3 hours. Furthermore, in a Monte-Carlo probabilistic sensitivity analysis, the early administration of TXA remained the dominant strategy (both lowered costs and improved outcomes) in 99.8% of models. CONCLUSION Early administration of TXA is a cost-effective strategy for reducing maternal morbidity and mortality due to postpartum hemorrhage in the US.
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Affiliation(s)
- Dagnie C Howard
- University of Arizona, Tucson, AZ; Oregon Health & Science University, Portland, OR.
| | | | - Ashley Skeith
- University of Michigan, Ann Arbor, MI; Oregon Health & Science University, Portland, OR
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38
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D'Souza R. Going with the Flow. Amer Scientist 2022. [DOI: 10.1511/2022.110.6.376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Ashraf R, Maxwell C, D'Souza R. Induction of labour in pregnant individuals with obesity. Best Pract Res Clin Obstet Gynaecol 2021; 79:70-80. [PMID: 35031244 DOI: 10.1016/j.bpobgyn.2021.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 12/14/2022]
Abstract
People with obesity may require induction of labour (IoL) due to a higher incidence of pre-existing comorbidities and pregnancy complications, as well as to prevent post-term pregnancies and late-term stillbirths. IoL at 39-40 weeks is associated with fewer caesarean births and lower morbidity for the pregnant person and neonate when compared with expectant management. Ensuring the success and safety of IoL in people with obesity requires adherence to evidence-based protocols for the management of labour induction and augmentation. Cervical ripening as well as the latent and active phases of labour in people with obesity may be considerably prolonged, requiring higher cumulative doses of oxytocin. This should be guided by intrauterine pressure catheters and early provision of neuraxial analgesia, where possible. There is insufficient evidence to recommend one method of IoL over another. The need for higher doses of prostaglandins and concurrent agents for cervical ripening should be studied in prospective studies.
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Affiliation(s)
- Rizwana Ashraf
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Cynthia Maxwell
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada; Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada; Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
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40
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D'Souza R, Malhamé I, Shah PS. Evaluating perinatal outcomes during a pandemic: A role for living systematic reviews. Acta Obstet Gynecol Scand 2021; 101:4-6. [PMID: 34927247 DOI: 10.1111/aogs.14305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/02/2021] [Accepted: 12/02/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Rohan D'Souza
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Isabelle Malhamé
- Division of General Internal Medicine, Department of Medicine and Research Institute, McGill University Health Centre, Montreal, Canada
| | - Prakesh S Shah
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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41
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Agarwal S, D'Souza R, Dy J. Induction of labour in patients with prior caesarean births or uterine surgery. Best Pract Res Clin Obstet Gynaecol 2021; 79:95-106. [PMID: 35012884 DOI: 10.1016/j.bpobgyn.2021.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 11/02/2022]
Abstract
The current evidence favours trial of labour after one caesarean in the absence of any other contraindications, recognizing that risks with both trial of labour after caesarean (TOLAC) and elective repeat caesarean section (ERCS) birth are relatively uncommon. When the need for induction of labour (IOL) following a previous caesarean arises, shared decision-making should be based on the current available evidence. This approach, however, needs to be tailored, taking into account the individual's history, initial examination and response to the ongoing process of induction to optimize the maternal and foetal outcomes. This paper aims to review the evidence and provide guidance on decision making surrounding labour induction in a pregnancy following a prior caesarean or uterine surgery.
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Affiliation(s)
- Sugandha Agarwal
- Ottawa Hospital Research Institute, The Ottawa Hospital, 501 Smyth Road, Ottawa, K1H8L6, ON, Canada.
| | - Rohan D'Souza
- Department of Obstetrics and Gynecology, McMaster University, 501 Smyth Road, Ottawa, K1H8L6, ON, Canada.
| | - Jessica Dy
- Department of Obstetrics and Gynecology, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, K1H8L6, Canada.
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42
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Pfaller B, Wichert-Schmitt B, Spears D, D'Souza R, Silversides CK. Tachycardia-induced cardiomyopathy in three consecutive pregnancies. Obstet Med 2021; 14:269-271. [PMID: 34880944 DOI: 10.1177/1753495x20958853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 08/25/2020] [Indexed: 11/16/2022] Open
Abstract
Tachycardia-induced cardiomyopathy is rare during pregnancy and is reversible when the underlying arrhythmia is effectively treated. Management can be complex due to the risks of antiarrhythmic medications and cardiac interventions on the developing fetus. The care requires a well-coordinated multidisciplinary team of cardiologists, electrophysiologists, and maternal-fetal specialists. In this report, we describe a case of recurrent atrial tachycardia-induced cardiomyopathy in pregnancy.
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Affiliation(s)
- Birgit Pfaller
- Department of Medicine, Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program and Obstetric Medicine Program, Mount Sinai and Toronto General Hospitals, Toronto, Ontario, Canada
| | - B Wichert-Schmitt
- Department of Medicine, Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program and Obstetric Medicine Program, Mount Sinai and Toronto General Hospitals, Toronto, Ontario, Canada.,Faculty of Medicine, Department of Cardiology and Medical Intensive Care, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Danna Spears
- Department of Medicine, Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program and Obstetric Medicine Program, Mount Sinai and Toronto General Hospitals, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Faculty of Medicine, Department of Cardiology and Medical Intensive Care, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Candice K Silversides
- Department of Medicine, Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program and Obstetric Medicine Program, Mount Sinai and Toronto General Hospitals, Toronto, Ontario, Canada
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43
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D'Souza R, Ashraf R, Foroutan F. Prediction models for determining the success of labour induction: A systematic review and critical analysis. Best Pract Res Clin Obstet Gynaecol 2021; 79:42-54. [DOI: 10.1016/j.bpobgyn.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 01/03/2023]
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44
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Yang J, D'Souza R, Kharrat A, Fell DB, Snelgrove JW, Murphy KE, Shah PS. Coronavirus disease 2019 pandemic and pregnancy and neonatal outcomes in general population: A living systematic review and meta-analysis (updated Aug 14, 2021). Acta Obstet Gynecol Scand 2021; 101:7-24. [PMID: 34730232 PMCID: PMC8653307 DOI: 10.1111/aogs.14277] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 12/13/2022]
Abstract
Introduction Conflicting reports of increases and decreases in rates of preterm birth (PTB) and stillbirth in the general population during the coronavirus disease 2019 (COVID‐19) pandemic have surfaced. The objective of our study was to conduct a living systematic review and meta‐analyses of studies reporting pregnancy and neonatal outcomes by comparing the pandemic and pre‐pandemic periods. Material and methods We searched PubMed and Embase databases, reference lists of articles published up until August 14, 2021 and included English language studies that compared outcomes between the COVID‐19 pandemic time period and the pre‐pandemic time periods. Risk of bias was assessed using the Newcastle–Ottawa scale. We conducted random‐effects meta‐analysis using the inverse variance method. Results Forty‐five studies with low‐to‐moderate risk of bias, reporting on 1 843 665 pregnancies during the pandemic period and 23 564 552 pregnancies during the pre‐pandemic period, were included. There was significant reduction in unadjusted estimates of PTB (35 studies, unadjusted odds ratio [uaOR] 0.95, 95% CI 0.92–0.98), but not in adjusted estimates (six studies, adjusted OR [aOR] 0.95, 95% CI 0.80–1.13). This reduction was noted in studies from single centers/health areas (25 studies, uaOR 0.90, 95% CI 0.86–0.96) but not in regional/national studies (10 studies, uaOR 0.99, 95% CI 0.95–1.02). There was reduction in spontaneous PTB (six studies, uaOR 0.89, 95% CI 0.81–0.96) and induced PTB (five studies, uaOR 0.89, 95% CI 0.81–0.97). There was no difference in the odds of stillbirth between the pandemic and pre‐pandemic time periods (24 studies, uaOR 1.11, 95% CI 0.97–1.26 and four studies, aOR 1.06, 95% CI 0.81–1.38). There was an increase in mean birthweight during the pandemic period compared with the pre‐pandemic period (six studies, mean difference 17 g, 95% CI 7–28 g). The odds of maternal mortality were increased (four studies, uaOR 1.15, 95% CI 1.05–1.26); however, only unadjusted estimates were available and the result was mostly influenced by one study from Mexico. There was significant publication bias for the outcome of PTB. Conclusions The COVID‐19 pandemic may be associated with a reduction in PTB; however, referral bias cannot be excluded. There was no statistically significant difference in stillbirth between pandemic and pre‐pandemic periods.
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Affiliation(s)
- Jie Yang
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ashraf Kharrat
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Deshayne B Fell
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - John W Snelgrove
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kellie E Murphy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Prakesh S Shah
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada.,Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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45
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Moores G, D'Souza R, Bui E. Anticonvulsivants et grossesse. CMAJ 2021; 193:E1578-E1579. [PMID: 34642163 PMCID: PMC8568077 DOI: 10.1503/cmaj.210065-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Ginette Moores
- Division de neurologie, Département de médecine (Moores, Bui), Université de Toronto; Division de médecine maternelle et fœtale, Département d'obstétrique et de gynécologie (D'Souza), Hôpital Mount Sinai, Université de Toronto, Toronto, Ont
| | - Rohan D'Souza
- Division de neurologie, Département de médecine (Moores, Bui), Université de Toronto; Division de médecine maternelle et fœtale, Département d'obstétrique et de gynécologie (D'Souza), Hôpital Mount Sinai, Université de Toronto, Toronto, Ont
| | - Esther Bui
- Division de neurologie, Département de médecine (Moores, Bui), Université de Toronto; Division de médecine maternelle et fœtale, Département d'obstétrique et de gynécologie (D'Souza), Hôpital Mount Sinai, Université de Toronto, Toronto, Ont.
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46
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Angamuthu N, Gilliland J, Chowdhury S, D'Souza R, Hart C, Knowles J. 293 A Reflection of Experience Gained in Emergency General Surgery During The COVID-19 Pandemic at A London University Hospital. Br J Surg 2021. [PMCID: PMC8524542 DOI: 10.1093/bjs/znab259.450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background During COVID-19, acute surgical services witnessed an overhaul of practice due to constraints on staff and resource (beds, imaging, and theater) availability. Fear of COVID-19, among general population potentially added to delay in patients seeking medical assistance. This study describes experiences of acute general surgery at a COVID-19 designated tertiary institution wherein elective surgical work was put on hold and emergency on-call rota was modified during the pandemic. Method A retrospective analysis (March-April 2019 vs 2020) of the surgical work from a prospectively maintained surgical database during COVID-19 was performed. Results Emergency surgical admissions during March 2020 vs 2019 was 106 vs 207. Comparing the workload March-April 2020 vs 2019, emergency referrals were 266 vs 341, operations performed 71 vs 92. 31.5% (84/266) of patients were tested for COVID and 30% (25/84) were positive. Emergency surgery was performed in 71 patients (including appendectomies (28), hernia repair(3), laparotomy(3), Hartman’s procedure(3), hemicolectomy(7) and anterior resection with covering ileostomy(2)). In this group, a male preponderance was noted (M:F 1.84:1), the average age was 43.2 years (6-91), length of stay 4.8 days (<23 hours-34 days). In the operative group, the 30-day mortality was 4.23% (3/71) and the morbidity was 31%. Conclusions With local changes, stopping elective services, modifying on-call rota, a surgical department can continue to be functional and offer emergency surgical service for a sustained period during a pandemic. During the COVID pandemic, the average number of referrals, admissions and surgeries were lower when compared to the non-covid period.
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Affiliation(s)
| | | | | | - R D'Souza
- Royal Free Hospital, London, United Kingdom
| | - C Hart
- Royal Free Hospital, London, United Kingdom
| | - J Knowles
- Royal Free Hospital, London, United Kingdom
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47
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Angamuthu N, Alagaratnam S, Varcada M, D'Souza R. 248 Rectus flap for repair of Strangulated Obturator Hernia. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Introduction
Obturator hernia (OH) is a rare abdominal wall hernia which commonly presents as small bowel obstruction. Surgical options include suture repair or use of autologous tissue or a mesh repair when primary suture repair is not feasible. We describe a case involving the use of the rectus abdominus muscle to repair a large OH.
Case report
An 81-year-old female presented with three days of abdominal distension and vomiting. A computerised tomography scan confirmed small bowel obstruction due to an obstructed left OH. At laparotomy, a short segment of non-viable distal ileum was reduced from the sac and resected with a primary anastomosis. The obturator defect was not amenable for suture approximation and due to concerns of possible mesh infection, the ipsilateral rectus muscle belly was mobilised from the anterior sheath, routed extra-peritoneally to plug the defect without tension. The muscle was anchored with prolene sutures to the cooper’s ligament, pectineus muscle and the fascia overlying the inner surface of inferior pubic ramus. Four months post-operatively, she has made an excellent recovery with no concerns currently.
Conclusions
In OH with a large defect precluding primary suture repair, a range of options have been described (use of autogenous peritoneal fold, pectineus muscle, round ligament, ovary, uterine fundus, omental and mesh plugs, and biological mesh). We believe, to plug and cover the defect, rectus muscle flap is a viable option giving a tension free robust repair, especially in patients with gangrenous bowel and local contamination.
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Affiliation(s)
| | | | - M Varcada
- Royal Free Hospital, London, United Kingdom
| | - R D'Souza
- Royal Free Hospital, London, United Kingdom
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48
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Angamuthu N, Alagaratnam S, D'Souza R, Varcada M. 249 Laparoscopic Assisted Enterolithotomy: A Viable Option in The Management of Gallstone Ileus. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Introduction
Gallstone ileus (GSI) is a rare cause of small bowel obstruction in patients over the age of 65 years. We report a case of GSI treated successfully with a laparoscopic assisted enterolithotomy.
Case report
A 75-year-old female presented with two days of abdominal distension and vomiting with a non-peritonitic abdomen on examination. A computerised tomography scan demonstrated small bowel obstruction due to an obstructing stone in the distal ileum. Three port laparoscopy and small bowel assessment confirmed a solitary enterolith (4cms) in the distal ileum with upstream dilated loops. An infra-umbilical 6 cm midline incision was made and the localised bowel loop was delivered. An enterotomy was made proximal to the point of obstruction, stone retrieved, and a single layer interrupted closure was performed. Ten weeks post-operatively, patient had a virtual follow-up consultation and is doing well.
Conclusions
GSI often presents in elderly patients with multiple co-morbidities. A laparotomy with enterolithotomy is the initial treatment of choice with biliary intervention as a second operation, if needed, at a later date. Clearly, a conventional exploratory laparotomy in this cohort of patients carries a high risk and therefore the use of less morbid and less invasive procedure like laparoscopy should be considered. Although a total laparoscopic approach would require advanced laparoscopic skills particularly due to dilated bowel loops limiting the intra-abdominal space for suturing, a laparoscopic assisted approach as described above should be considered as a reasonable option within the remits of an emergency general surgeon.
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Affiliation(s)
| | | | - R D'Souza
- Royal Free Hospital, London, United Kingdom
| | - M Varcada
- Royal Free Hospital, London, United Kingdom
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Thorne SA, Cook JL, D'Souza R. The Role of National Pregnancy Surveillance Systems in Improving Maternal Mortality and Morbidity: The Next Steps for Canada. Can J Cardiol 2021; 37:1904-1907. [PMID: 34474122 DOI: 10.1016/j.cjca.2021.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Sara A Thorne
- Division of Cardiology, Pregnancy and Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Jocelynn L Cook
- Department of Obstetrics and Gynecology, University of Ottawa, and the Society of Obstetricians and Gynaecologists of Canada, Ottawa, Ontario, Canada
| | - Rohan D'Souza
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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50
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Moores G, D'Souza R, Bui E. Antiseizure medications and pregnancy. CMAJ 2021; 193:E1253. [PMID: 34400484 PMCID: PMC8386483 DOI: 10.1503/cmaj.210065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Ginette Moores
- Division of Neurology, Department of Medicine (Moores, Bui), University of Toronto; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology (D'Souza), Mount Sinai Hospital, University of Toronto, Toronto, Ont
| | - Rohan D'Souza
- Division of Neurology, Department of Medicine (Moores, Bui), University of Toronto; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology (D'Souza), Mount Sinai Hospital, University of Toronto, Toronto, Ont
| | - Esther Bui
- Division of Neurology, Department of Medicine (Moores, Bui), University of Toronto; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology (D'Souza), Mount Sinai Hospital, University of Toronto, Toronto, Ont.
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