Correction: Oral misoprostol, low dose vaginal misoprostol, and vaginal dinoprostone for labor induction: Randomized controlled trial

[This corrects the article DOI: 10.1371/journal.pone.0227245.].

Committee Opinion No. 419: Coercion Free Contraceptive Care

OBJECTIVE

To provide guidance on culturally competent contraception counselling that is free of coercion and promotes shared decision-making and patient autonomy.

TARGET POPULATION

Individuals of reproductive age who seek contraception or counselling for family planning.

OPTIONS

Contraception counselling is provided within a rights-based family planning framework, where the individual's beliefs, culture, preferences, and ability to use the chosen method are respected.

OUTCOMES

To promote patient autonomy in decision-making surrounding family planning, including the right to access and use their contraceptive method of choice, to decline contraception or use less effective methods of contraception, and to freely choose to discontinue a method of contraception, as well as the right to unbiased, non-coercive contraception counselling and evidence-based information from their health care provider BENEFITS, HARMS, AND COSTS: Implementation of these recommendations would reduce real or perceived coercive contraceptive care, particularly among vulnerable populations, resulting in improved patient autonomy and a better patient experience in health care settings.

EVIDENCE

Databases searched: MEDLINE, Cochrane, PubMed, and CanLII. Medical terms used: contraception, family planning services, informed consent, coercion, decision making, sterilization, permanent contraception, counselling. Legal terms searched: forced sterilization, and aboriginal. Initial search conducted in 2020 and updated in 2021.

INTENDED AUDIENCE

This committee opinion is intended for health care providers (obstetricians, gynaecologists, family physicians, general surgeons, nurse practitioners, nurses, midwives, undergraduate/postgraduate medical trainees, and other health care providers) who provide sexual and reproductive health services.

Revisiting the Care Pathway for Trial of Labour After Cesarean: The Decision-to-Delivery Interval Is Key

Centres providing maternity care and offering a trial of labour after cesarean must develop and use maternal educational and consent processes that emphasize choice and autonomy related to options for and decisions surrounding vaginal birth after cesarean and elective repeat cesarean delivery. These centres should have administrative systems and processes that take into account local resources for cesarean delivery services, including team-based complex maternity risk support and an urgency consensus on the fetal, maternal, and maternal-fetal indications for a surgical delivery to ensure an appropriate decision-to-delivery interval.

Prioritizing Maternal Sepsis: National Adoption of an Obstetric Early Warning System to Prevent Morbidity and Mortality

Sepsis is one of the leading causes of maternal morbidity and mortality. Analyses have determined that delays in early recognition and prompt initiation of appropriate management are key contributing factors in maternal sepsis deaths. Recent cases of sepsis-related maternal morbidity and mortality across Canada have highlighted the urgent need for a national standardized approach to the detection and treatment of maternal sepsis. The SOGC has established a national multidisciplinary maternal sepsis task force to address this priority. The adoption of a national modified obstetric early warning system (MEOWS) is recommended as a key first step. This early warning scoring (EWS) system will facilitate early detection of maternal clinical deterioration and mandate timely escalation of care appropriate for the severity of illness. There is currently limited use of EWSs in Canada. Introducing a national EWS and a standardized maternal sepsis management guideline provides a tremendous opportunity to improve maternal care. A standardized approach will facilitate future evidence-based evaluation and refinement of the tool, and enable the reduction of preventable maternal morbidity and mortality from sepsis, as well as all causes duplicated.

Oral misoprostol, low dose vaginal misoprostol, and vaginal dinoprostone for labor induction: Randomized controlled trial

OBJECTIVE

To compare effectiveness and safety of oral misoprostol (50 μg every four hours as needed), low dose vaginal misoprostol (25 to 50 μg every six hours as needed), and our established dinoprostone vaginal gel (one to two mg every six hours as needed) induction.

MATERIALS AND METHODS

Consenting women with a live term single cephalic fetus for indicated labor induction were randomized (3N = 511). Prior uterine surgery or non-reassuring fetal surveillance were exclusions. Concealed computer generated randomization was stratified and blocked. Newborns were assessed by a team unaware of group assignment. The primary outcome was time from induction at randomization to vaginal birth for initial parametric analysis. Sample size was based on mean difference of 240 minutes with α2 = 0.05 and power 95%. Non-parametric analysis was also pre-specified ranking cesareans as longest vaginal births.

RESULTS

Enrollment was from April 1999 to December 2000. Demographics were similar across groups. Analysis was by intent to treat, with no loss to follow up. Mean time (±SD) to vaginal birth was 1356 (±1033) minutes for oral misoprostol, 1530 (±3249) minutes for vaginal misoprostol, and 1208 (±613) minutes for vaginal dinoprostone (P = 0.46, ANOVA). Median times to vaginal birth were 1571, 1339, and 1451 minutes respectively (P = 0.46, Kruskal-Wallis). Vaginal births occurred within 24 hours in 44.9, 53.5 and 47.7% respectively (P = 0.27, χ2). There were no significant differences in Kaplan Meier survival analyses, cesareans, adverse effects, or maternal satisfaction. The newborn who met birth asphyxia criteria received vaginal misoprostol, as did. all three other newborns with cord artery pH<7.0 (P = 0.04, Fisher Exact).

CONCLUSION

There was no significant difference in effectiveness of the three groups. Profound newborn acidemia, though infrequent, occurred only with low dose vaginal misoprostol.

Optimal Timing of Prenatal Ultrasound in Predicting Birth Weight in Diabetic Pregnancies

OBJECTIVE

This study sought to determine the optimal timing of ultrasound in the third trimester to predict birth weight accurately in diabetic women with a singleton pregnancy.

METHODS

A retrospective cohort study of all diabetic women with a singleton pregnancy treated in Halifax, Nova Scotia, was performed. Estimated fetal weight was derived from ultrasound measures using the Hadlock2 equation. The Mongelli equation was used to predict birth weight. The association between gestational age at ultrasound and accuracy of predicted birth weight was assessed, with accuracy as a continuous variable representing the difference between predicted and actual birth weight and as a categorical variable (with four gestational age categories) representing whether predicted birth weight was within, over, or under 250 g of actual birth weight RESULTS: The cohort of 943 women comprised 121 (12.8%) with type 1 diabetes, 111 (11.7%) with type 2 diabetes, and 711 (75.4%) with gestational diabetes. Ultrasound scans performed at term were the most accurate in predicting birth weight. At this gestational age, the mean difference between predicted and actual birth weight was -30 g (95% confidence interval -109 to -48). After adjusting for maternal body mass index, age, smoking, type of diabetes, and interval between ultrasound examination and delivery, accuracy improved as gestational age at ultrasound increased (P = 0.005). The odds of underpredicting or overpredicting birth weight were not significantly affected by the timing of the ultrasound examination.

CONCLUSION

Because the predictive accuracy of ultrasound prediction of birth weight improves with gestational age, fetal growth assessment at term is recommended to aid with delivery planning in women with diabetes.

Urinary stress incontinence and other maternal outcomes 2 years after caesarean or vaginal birth for twin pregnancy: a multicentre randomised trial

OBJECTIVE

Does planned caesarean compared with planned vaginal birth lower the risk of problematic urinary stress, faecal, or flatal incontinence?

DESIGN

Women between 32^0/7 and 38^6/7 weeks of gestation with a twin pregnancy were randomised to planned caesarean or planned vaginal birth.

SETTING

The trial took place at 106 centres in 25 countries.

POPULATION

A total of 2305 of the 2804 women enrolled in the study completed questionnaires at 2 years (82.2% follow-up): 1155 in the planned caesarean group and 1150 in the planned vaginal birth group.

METHODS

A structured self-administered questionnaire completed at 2 years postpartum.

MAIN OUTCOME MEASURES

The primary maternal outcome of the Twin Birth Study was problematic urinary stress, or fecal, or flatal incontinence at 2 years RESULTS: Women in the planned caesarean group had lower problematic urinary stress incontinence rates compared with women in the planned vaginal birth group [93/1147 (8.11%) versus 140/1143 (12.25%); odds ratio, 0.63; 95% confidence interval, 0.47-0.83; P = 0.001]. Among those with problematic urinary stress incontinence, quality of life (measured using the Incontinence Impact Questionnaire, IIQ-7) was not different for planned caesarean versus planned vaginal birth groups [mean (SD): 18.4 (21.0) versus 19.1 (21.5); P = 0.82]. There were no differences in problematic faecal or flatal incontinence, or in other maternal outcomes.

CONCLUSIONS

Among women with a twin pregnancy and no prior history of urinary stress incontinence, a management strategy of planned caesarean compared with planned vaginal birth reduces the risk of problematic urinary stress incontinence at 2 years postpartum. Our findings show that the prevalence but not the severity of urinary stress incontinence was associated with mode of birth.

FUNDING

Canadian Institutes of Health Research (CIHR) (grant no. MCT-63164).

TWEETABLE ABSTRACT

For women with twins, planned caesarean compared with planned vaginal birth is associated with decreased prevalence but not severity of urinary stress incontinence at 2 years.

Examining the provisional guidelines for weight gain in twin pregnancies: a retrospective cohort study

BACKGROUND

Weight gain during pregnancy has an important impact on maternal and neonatal health. Unlike the Institute of Medicine (IOM) recommendations for weight gain in singleton pregnancies, those for twin gestations are termed "provisional", as they are based on limited data. The objectives of this study were to determine the neonatal and maternal outcomes associated with gaining weight below, within and above the IOM provisional guidelines on gestational weight gain in twin pregnancies, and additionally, to explore ranges of gestational weight gain among women who delivered twins at the recommended gestational age and birth weight, and those who did not.

METHODS

A retrospective cohort study of women who gave birth to twins at ≥20 weeks gestation, with a birth weight ≥ 500 g was conducted in Nova Scotia, Canada (2003-2014). Our primary outcome of interest was small for gestational age (<10th percentile). In order to account for gestational age at delivery, weekly rates of 2nd and 3rd trimester weight gain were used to categorize women as gaining below, within, or above guidelines. We performed traditional regression analyses for maternal outcomes, and to account for the correlated nature of the neonatal outcomes in twins, we used generalized estimating equations (GEE).

RESULTS

A total of 1482 twins and 741 mothers were included, of whom 27%, 43%, and 30% gained below, within, and above guidelines, respectively. The incidence of small for gestational age in these three groups was 30%, 21%, and 20%, respectively, and relative to gaining within guidelines, the adjusted odds ratios were 1.44 (95% CI 1.01-2.06) for gaining below and 0.92 (95% CI 0.62-1.36) for gaining above. The gestational weight gain in women who delivered twins at 37-42 weeks with average birth weight ≥ 2500 g and those who delivered twins outside of the recommend ranges were comparable to each other and the IOM recommendations.

CONCLUSIONS

While gestational weight gain below guidelines for twins was associated with some adverse neonatal outcomes, additional research exploring alternate ranges of gestational weight gain in twin pregnancies is warranted, in order to optimize neonatal and maternal outcomes.

Gestational Weight Gain and Interpregnancy Weight Change in Adolescent Mothers

STUDY OBJECTIVE

To examine the association between gestational weight gain (GWG) and interpregnancy weight change (IPWC) in adolescent mothers (younger than 20 years), and to determine if this association differs from adult women (aged 20-35 years).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We included 3055 adolescents and 17,090 adult women with singleton pregnancies recorded in the Nova Scotia Atlee Perinatal Database with a subsequent pregnancy occurring between 2003 and 2014.

INTERVENTIONS AND MAIN OUTCOME MEASURES

GWG in the first pregnancy was categorized as below, within, or above the current Institute of Medicine recommendations. IPWC was defined as the difference between the prepregnancy weights of the 2 pregnancies. Analyses were adjusted for parity, body mass index in the first pregnancy, and time between pregnancies.

RESULTS

Relative to adolescents with GWG within the recommendations, those who gained below had a 2.7 kg (95% confidence interval [CI], 1.4-3.9) lower mean IPWC whereas those who gained above had a 4.2 kg (95% CI, 3.3-5.1) higher mean IPWC. Smaller differences in IPWC between GWG categories were observed in adult women; relative to those with GWG within the recommendations, adults who gained below had a 1.3 kg (95% CI, 0.9-1.7) lower mean IPWC and those who gained above had a 2.9 kg (95% CI, 2.6-3.2) higher mean IPWC.

CONCLUSION

Mean IPWC differed across GWG categories and the differences were greater in adolescents than in adult women. This difference should be considered when assessing whether specific GWG recommendations are needed for adolescents.

Determinants of vitamin D status in pregnant women and neonates

OBJECTIVES

Evidence suggests a beneficial effect of vitamin D on perinatal health; however, low vitamin D status is prevalent in pregnant women and neonates. The objective was to determine factors that are associated with vitamin D status of mothers in early pregnancy and neonates.

METHODS

The study comprised 1,635 pregnant women from Quebec City and Halifax, Canada, 2002-2010. Vitamin D status was based on the concentration of 25-hydroxy-vitamin D [25(OH)D] determined with a chemiluminescence immunoassay in maternal sera collected at a median of 15 weeks' gestation and in neonatal cord sera at delivery. A questionnaire with information on potential determinants was completed midpregnancy.

RESULTS

A total of 44.8% of mothers and 24.4% of neonates had 25(OH)D concentrations &lt;50 nmol/L. Adjusted mean (95% confidence interval) maternal 25(OH)D levels were higher in summer than in winter by 16.1 nmol/L (13.6-18.7), and in those in the highest versus the lowest category of education by 6.1 nmol/L (0.5-11.8), in BMI &lt;25 kg/m2 versus BMI ≥35 kg/m2 by 8.2 nmol/L (4.0-12.3), and in the highest versus the lowest physical activity category by up to 9.5 nmol/L (2.9-16.1). Determinants of neonatal 25(OH)D levels were similar but also included maternal age, dairy intake, supplement use and 25(OH)D level.

CONCLUSION

This study suggests that vitamin D status of pregnant women and/or neonates might be improved through supplementation, adequate dairy intake, a move towards a healthy pre-pregnancy body weight, and participation in physical activity. Controlled studies are needed to determine the effectiveness of interventions aimed at these factors.

Vitamin D Status and Gestational Diabetes: Effect of Smoking Status during Pregnancy

BACKGROUND

Vitamin D status, as measured by serum 25-hydroxyvitamin D (25(OH)D), has been shown in some studies to be inversely associated with gestational diabetes risk. Recently, it has been suggested that maternal smoking status may modify this relationship. We explored the association between 25(OH)D concentration and gestational diabetes and determined if there was an interaction between smoking and 25(OH)D.

METHODS

A nested case-control study was conducted in Halifax, Nova Scotia and Quebec City, Quebec. Women were recruited before 20 weeks gestation and 25(OH)D was measured. Cases were women who developed gestational diabetes and controls were frequency matched to cases on study site, gestational age at blood draw, and season and year of blood draw. Logistic regression models estimated adjusted odds ratios (aOR) and 95% confidence intervals (CI). Models were tested for multiplicative and additive interaction, which was estimated by relative excess risk due to interaction (RERI).

RESULTS

The study included 395 gestational diabetes cases and 1925 controls. Women who smoked during pregnancy and had 25(OH)D concentrations <30 nmol/L had an aOR = 3.73 [95% CI 1.95, 7.14] compared to non-smokers with 25(OH)D concentrations ≥50 nmol/L. Additive interaction was detected between smoking status and 25(OH)D [RERI = 2.44, 95% CI 0.03, 4.85].

CONCLUSION

Our study supports the inverse association of vitamin D status with gestational diabetes risk, particularly among women who smoke during pregnancy. More research is needed to confirm this finding and, if confirmed, to determine the mechanism by which the combined effect of smoking and low vitamin D status increases the risk of developing gestational diabetes.

Twin Birth Study: 2-year neurodevelopmental follow-up of the randomized trial of planned cesarean or planned vaginal delivery for twin pregnancy

BACKGROUND

The Twin Birth Study randomized women with uncomplicated pregnancies, between 32(0/7)-38(6/7) weeks' gestation where the first twin was in cephalic presentation, to a policy of either a planned cesarean or planned vaginal delivery. The primary analysis showed that planned cesarean delivery did not increase or decrease the risk of fetal/neonatal death or serious neonatal morbidity as compared with planned vaginal delivery.

OBJECTIVE

This study presents the secondary outcome of death or neurodevelopmental delay at 2 years of age.

STUDY DESIGN

A total of 4603 children from the initial cohort of 5565 fetuses/infants (83%) contributed to the outcome of death or neurodevelopmental delay. Surviving children were screened using the Ages and Stages Questionnaire with abnormal scores validated by a clinical neurodevelopmental assessment. The effect of planned cesarean vs planned vaginal delivery on death or neurodevelopmental delay was quantified using a logistic model to control for stratification variables and using generalized estimating equations to account for the nonindependence of twin births.

RESULTS

Baseline maternal, pregnancy, and infant characteristics were similar. Mean age at assessment was 26 months. There was no significant difference in the outcome of death or neurodevelopmental delay: 5.99% in the planned cesarean vs 5.83% in the planned vaginal delivery group (odds ratio, 1.04; 95% confidence interval, 0.77-1.41; P = .79).

CONCLUSION

A policy of planned cesarean delivery provides no benefit to children at 2 years of age compared with a policy of planned vaginal delivery in uncomplicated twin pregnancies between 32(0/7)-38(6/7)weeks' gestation where the first twin is in cephalic presentation.

Umbilical Cord Blood: Counselling, Collection, and Banking

OBJECTIVE

To review current evidence regarding umbilical cord blood counselling, collection, and banking and to provide guidelines for Canadian health care professionals regarding patient education, informed consent, procedural aspects, and options for cord blood banking in Canada.

OPTIONS

Selective or routine collection and banking of umbilical cord blood for future stem cell transplantation for autologous (self) or allogeneic (related or unrelated) treatment of malignant and non-malignant disorders in children and adults. Cord blood can be collected using in utero or ex utero techniques.

OUTCOMES

Umbilical cord blood counselling, collection, and banking, education of health care professionals, indications for cord blood collection, short- and long-term risk and benefits, maternal and perinatal morbidity, parental satisfaction, and health care costs.

EVIDENCE

Published literature was retrieved through searches of Medline and PubMed beginning in September 2013 using appropriate controlled MeSH vocabulary (fetal blood, pregnancy, transplantation, ethics) and key words (umbilical cord blood, banking, collection, pregnancy, transplantation, ethics, public, private). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Umbilical cord blood is a readily available source of hematopoetic stem cells used with increasing frequency as an alternative to bone marrow or peripheral stem cell transplantation to treat malignant and non-malignant conditions in children and adults. There is minimal harm to the mother or newborn provided that priority is given to maternal/newborn safety during childbirth management. Recipients of umbilical cord stem cells may experience graft-versus-host disease, transfer of infection or genetic abnormalities, or therapeutic failure. The financial burden on the health system for public cord blood banking and on families for private cord blood banking is considerable. Recommendations 1. Health care professionals should be well-informed about cord blood collection and storage and about factors that influence the volume, quality, and ability to collect a cord blood unit. (III-A) 2. Health care professionals caring for women and families who choose private umbilical cord blood banking must disclose any financial interests or potential conflicts of interest. (III-A) 3. Pregnant women should be provided with unbiased information about umbilical cord blood banking options, including the benefits and limitations of public and private banks. (III-A) 4. Health care professionals should obtain consent from mothers for the collection of umbilical cord blood prior to the onset of active labour, ideally during the third trimester, with ample time to address any questions. (III-A) 5. Health care professionals must be trained in standardized procedures (ex utero and in utero techniques) for cord blood collection to ensure the sterility and quality of the collected unit. (II-2A) 6. Umbilical cord blood should be collected with the goal of maximizing the content of hematopoietic progenitors through the volume collected. The decision to bank the unit will depend upon specific measures of graft potency. (II-2A) 7. Umbilical cord blood collection must not adversely affect the health of the mother or newborn. Cord blood collection should not interfere with delayed cord clamping. (III-E) 8. Health care professionals should inform pregnant women and their partners of the benefits of delayed cord clamping and of its impact on cord blood collection and banking. (II-2A) 9. Cord blood units collected for public or private banking can be used for biomedical research, provided consent is obtained, when units cannot be banked or when consent for banking is withdrawn. (II-3B) 10. Mothers may be approached to donate cells for biomedical research. Informed consent for research using cord blood should ideally be obtained prior to the onset of active labour or elective Caesarean section following established research ethics guidelines. (II-2A).

An Algorithm for Predicting Neonatal Mortality in Threatened Very Preterm Birth

OBJECTIVE

To develop a prediction model for neonatal mortality using information readily available in the antenatal period.

METHODS

A multiple logistic regression model of a complete population-based geographically defined cohort of very preterm infants of 23+0 to 30+6 weeks' gestation was used to identify antenatal factors which were predictive of mortality in this population. Infants lt; 23 weeks and those with major anomalies were excluded.

RESULTS

Between 1996 and 2012, 1240 live born infants lt; 31 weeks' gestation were born to women residing in Nova Scotia. Decreasing gestational age strongly predicted an increased mortality rate. Other factors significantly contributing to increased mortality included classification as small for gestational age, oligohydramnios, maternal psychiatric disorders, antenatal antibiotic therapy, and monochorionic twins. Reduced neonatal mortality was associated with antenatal use of antihypertensive agents and use of corticosteroids of any duration of therapy given at least 24 hours before delivery. An algorithm was developed to estimate the risk of mortality without the need for a calculator.

CONCLUSION

Prediction of the probability of neonatal mortality is influenced by maternal and fetal factors. An algorithm to estimate the risk of mortality facilitates counselling and informs shared decision making regarding obstetric management.

The association between physical activity and maternal and neonatal outcomes: a prospective cohort

Some evidence, but not enough to be conclusive, suggests that physical activity in pregnancy reduces the risk of perinatal complications. Our objective was to examine if physical activity in the year before pregnancy and in the first half of pregnancy is associated with maternal and neonatal outcomes. Associations between physical activity and maternal and neonatal outcomes were examined in a prospective cohort (n = 1,749) in Halifax, Canada. The Kaiser Physical Activity Survey, completed at approximately 20 weeks' gestation, requested information regarding physical activity during the year before the pregnancy and the first 20 weeks of pregnancy. Outcomes were assessed by medical chart review. Multiple logistic regression was used to estimate odds ratios (OR) with 95 % confidence intervals (CI). Women with prepregnancy physical activity levels in the middle and highest tertiles were more likely to have high gestational weight gain relative to women in the lowest tertile [OR (CI): 1.40 (1.06-1.85) and 1.57 (1.18-2.09), respectively]. Higher physical activity in the first half of pregnancy decreased the odds of delivering a macrosomic infant (p trend = 0.005). Associations were not observed between total physical activity and gestational diabetes, gestational hypertension, pre-eclampsia, preterm birth, and low birth weight. Physical activity before, but not in the first half of pregnancy, is associated with high gestational weight gain. Physical activity in the first half of pregnancy may reduce the occurrence of macrosomia without affecting preterm birth or low birth weight.

Maternal outcomes at 3 months after planned caesarean section versus planned vaginal birth for twin pregnancies in the Twin Birth Study: a randomised controlled trial

OBJECTIVE

To compare outcomes at 3 months post partum for women randomised to give birth by planned caesarean section (CS) or by planned vaginal birth (VB) in the Twin Birth Study (TBS).

DESIGN

We invited women in the TBS to complete a 3-month follow-up questionnaire.

SETTING

Two thousand and eight hundred and four women from 25 countries.

POPULATION

Two thousand and five hundred and seventy women (92% response rate).

METHODS

Women randomised between 13 December 2003 and 4 April 2011 in the TBS completed a questionnaire and outcomes were compared using an intention-to-treat approach.

MAIN OUTCOME AND MEASURES

Breastfeeding, quality of life, depression, fatigue and urinary incontinence.

RESULTS

We found no clinically important differences between groups in any outcome. In the planned CS versus planned VB groups, breastfeeding at any time after birth was reported by 84.4% versus 86.4% (P = 0.13); the mean physical and mental Short Form (36) Health Survey (SF-36) quality of life scores were 51.8 versus 51.6 (P = 0.65) and 46.7 versus 46.0 (P = 0.09), respectively; the mean Multidimensional Assessment of Fatigue score was 20.3 versus 20.8 (P = 0.14); the frequency of probable depression on the Edinburgh Postnatal Depression Scale was 14.0% versus 14.8% (P = 0.57); the rate of problematic urinary incontinence was 5.5% versus 6.4% (P = 0.31); and the mean Incontinence Impact Questionnaire-7 score was 20.5 versus 20.4 (P = 0.99). Partner relationships, including painful intercourse, were similar between the groups.

CONCLUSION

For women with twin pregnancies randomised to planned CS compared with planned VB, outcomes at 3 months post partum did not differ. The mode of birth was not associated with problematic urinary incontinence or urinary incontinence that affected the quality of life. Contrary to previous studies, breastfeeding at 3 months was not increased with planned VB.

TWEETABLE ABSTRACT

Planned mode of birth for twins doesn't affect maternal depression, wellbeing, incontinence or breastfeeding.

Multiple courses of antenatal corticosteroids for preterm birth study: outcomes in children at 5 years of age (MACS-5)

IMPORTANCE

A single course of antenatal corticosteroid therapy is recommended for pregnant women at risk of preterm birth between 24 and 33 weeks' gestational age. However, 50% of women remain pregnant 7 to 14 days later, leading to the question of whether additional courses should be given to women remaining at risk for preterm birth. The Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study (MACS) was an international randomized clinical trial that compared multiple courses of antenatal corticosteroids with a single course in women at risk of preterm birth.

OBJECTIVE

To determine the effects of single vs multiple courses of antenatal corticosteroid therapy on death or neurodevelopmental disability (neuromotor, neurosensory, or neurocognitive/neurobehavioral function) at 5 years of age in children whose mothers participated in MACS. Our secondary aims were to determine the effect on height, weight, head circumference, blood pressure, intelligence, and specific cognitive (visual, spatial, and language) skills.

DESIGN, SETTING, AND PARTICIPANTS

Cohort follow-up study of children seen between June 2006 and May 2012 at 55 centers. In total, 1724 women (2141 children) were eligible for the study, of whom 1728 children (80.7% of the 2141 eligible children) participated and 1719 children contributed to the primary outcome.

INTERVENTION

Single and multiple courses of antenatal corticosteroid therapy.

MAIN OUTCOMES AND MEASURES

The primary outcome was death or survival with a neurodevelopmental disability in 1 of the following domains: neuromotor (nonambulatory cerebral palsy), neurosensory (blindness, deafness, or need for visual/hearing aids), or neurocognitive/neurobehavioral function (abnormal attention, memory, or behavior).

RESULTS

There was no significant difference between the groups in the risk of death or neurodevelopmental disability: 217 of 871 children (24.9%) in the multiple-courses group vs 210 of 848 children (24.8%) in the single-course group (odds ratio, 1.02 [95% CI, 0.81 to 1.29]; P = .84).

CONCLUSIONS AND RELEVANCE

Multiple courses, compared with a single course, of antenatal corticosteroid therapy did not increase or decrease the risk of death or disability at 5 years of age. Because of a lack of strong conclusive evidence of short-term or long-term benefits, it remains our opinion that multiple courses not be recommended in women with ongoing risk of preterm birth.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00187382.

Preterm prelabour rupture of membranes: effect of latency on neonatal and maternal outcomes

OBJECTIVES

To compare risks of infection and prematurity-related outcomes according to latency periods among women with preterm prelabour rupture of membranes (PPROM).

METHODS

Women with PPROM occurring between 24+0 and 36+6 weeks of gestation were identified from a provincial population-based perinatal database in Nova Scotia. The primary outcomes included composite variables for serious maternal and neonatal infectious morbidity and neonatal prematurity-related morbidity. Logistic regression was used to quantify the relationship between latency period (< 24 hours, 24 hours to < 48 hours, 48 hours to < 7 days, and ≥ 7 days) and maternal and neonatal outcomes. Separate analyses were conducted for gestational age groups 24+0 to 33+6 weeks and 34+0 to 36+6 weeks.

RESULTS

There were 4329 women included in the cohort. The composite variables representing serious maternal or neonatal infectious morbidity were not significantly associated with latency for either gestational age group. For PPROM occurring at gestational ages of 24+0 to 33+6 weeks, the odds of neonatal prematurity-related morbidity were significantly decreased at the latency periods of 48 hours or more compared with < 24 hours latency. For PPROM at 34+0 to 36+6 weeks of gestation, the odds of prematurity-related morbidity at 48 hours to < 7 days latency was decreased compared with latencies < 24 hours (OR 0.4; 95% CI 0.2 to 0.8).

CONCLUSION

Postponing delivery following PPROM may contribute to less prematurity-related morbidity, even close to term, without putting mother or neonate at substantial risk for serious infectious morbidity. Generalization of these findings to other obstetric populations should be informed by the underlying risk of infection.

A randomized trial of planned cesarean or vaginal delivery for twin pregnancy

BACKGROUND

Twin birth is associated with a higher risk of adverse perinatal outcomes than singleton birth. It is unclear whether planned cesarean section results in a lower risk of adverse outcomes than planned vaginal delivery in twin pregnancy.

METHODS

We randomly assigned women between 32 weeks 0 days and 38 weeks 6 days of gestation with twin pregnancy and with the first twin in the cephalic presentation to planned cesarean section or planned vaginal delivery with cesarean only if indicated. Elective delivery was planned between 37 weeks 5 days and 38 weeks 6 days of gestation. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity, with the fetus or infant as the unit of analysis for the statistical comparison.

RESULTS

A total of 1398 women (2795 fetuses) were randomly assigned to planned cesarean delivery and 1406 women (2812 fetuses) to planned vaginal delivery. The rate of cesarean delivery was 90.7% in the planned-cesarean-delivery group and 43.8% in the planned-vaginal-delivery group. Women in the planned-cesarean-delivery group delivered earlier than did those in the planned-vaginal-delivery group (mean number of days from randomization to delivery, 12.4 vs. 13.3; P=0.04). There was no significant difference in the composite primary outcome between the planned-cesarean-delivery group and the planned-vaginal-delivery group (2.2% and 1.9%, respectively; odds ratio with planned cesarean delivery, 1.16; 95% confidence interval, 0.77 to 1.74; P=0.49).

CONCLUSIONS

In twin pregnancy between 32 weeks 0 days and 38 weeks 6 days of gestation, with the first twin in the cephalic presentation, planned cesarean delivery did not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00187369; Current Controlled Trials number, ISRCTN74420086.).

A randomized controlled trial of the effect of intrapartum intravenous fluid management on breastfed newborn weight loss

OBJECTIVE

To determine the effect of conservative versus usual intrapartum intravenous (IV) fluid management for low-risk women receiving epidural analgesia on weight loss in breastfed newborns.

DESIGN

A randomized controlled trial.

SETTING

A tertiary perinatal center in a large urban setting.

SAMPLE

Women experiencing uncomplicated pregnancies who planned to have epidural analgesia and to breastfeed.

METHODS

Healthy pregnant women were randomized to receive an IV epidural preload volume of <500 mLs continuing at an hourly rate of 75-100 mL/h (conservative care) or an epidural preload volume of ≥500 mLs and an hourly rate >125 mL/h (usual care). The primary study outcome was breastfed newborn weight loss >7% prior to hospital discharge. Secondary study outcomes included breastfeeding exclusivity, referral to outpatient breastfeeding clinic support, and delayed discharge. Other outcomes were admission to the neonatal intensive care unit and cord blood pH <7.25.

RESULTS

Two hundred women participated (100 in the conservative care and 100 in the usual care groups). Forty-eight of 100 infants in the usual care group and 44 of the 100 infants in the conservative care group lost >7% of their birth weight prior to discharge, p < 0.52 RR 0.92 [0.68-1.24].

CONCLUSION

A policy of restricted IV fluids did not affect newborn weight loss. Women and their care providers should be reassured that the volumes of IV fluid <2500 mLs are unlikely to have a clinically meaningful effect on breastfed newborn weight loss >7%. Exploratory analyses suggest that breastfed newborn weight loss increases when intrapartum volumes infused are >2500 mLs. Care providers are encouraged to consider volumes of IV fluid infused intrapartum as a factor that may have contributed to early newborn weight loss in the first 48 h of life.

The role of prenatal, obstetric and neonatal factors in the development of autism

We conducted a linked database cohort study of infants born between 1990 and 2002 in Nova Scotia, Canada. Diagnoses of autism were identified from administrative databases with relevant diagnostic information to 2005. A factor representing genetic susceptibility was defined as having an affected sibling or a mother with a history of a psychiatric or neurologic condition. Among 129,733 children, there were 924 children with an autism diagnosis. The results suggest that among those with low genetic susceptibility, some maternal and obstetric factors may have an independent role in autism etiology whereas among genetically susceptible children, these factors appear to play a lesser role. The role of pre-pregnancy obesity and excessive weight gain during pregnancy on autism risk require further investigation.

Maternal side-effects after multiple courses of antenatal corticosteroids (MACS): the three-month follow-up of women in the randomized controlled trial of MACS for preterm birth study

OBJECTIVE

A single course of antenatal corticosteroids (ACS) is associated with a reduction in respiratory distress syndrome and neonatal death. Multiple Courses of Antenatal Corticosteroids Study (MACS), a study involving 1858 women, was a multicentre randomized placebo-controlled trial of multiple courses of ACS, given every 14 days until 33+6 weeks or birth, whichever came first. The primary outcome of the study, a composite of neonatal mortality and morbidity, was similar for the multiple ACS and placebo groups (12.9% vs. 12.5%), but infants exposed to multiple courses of ACS weighed less, were shorter, and had smaller head circumferences. Thus for women who remain at increased risk of preterm birth, multiple courses of ACS (every 14 days) are not recommended. Chronic use of corticosteroids is associated with numerous side effects including weight gain and depression. The aim of this postpartum assessment was to ascertain if multiple courses of ACS were associated with maternal side effects.

METHODS

Three months postpartum, women who participated in MACS were asked to complete a structured questionnaire that asked about maternal side effects of corticosteroid use during MACS and included the Edinburgh Postnatal Depression Scale. Women were also asked to evaluate their study participation.

RESULTS

Of the 1858 women randomized, 1712 (92.1%) completed the postpartum questionnaire. There were no significant differences in the risk of maternal side effects between the two groups. Large numbers of women met the criteria for postpartum depression (14.1% in the ACS vs. 16.0% in the placebo group). Most women (94.1%) responded that they would participate in the trial again.

CONCLUSION

In pregnancy, corticosteroids are given to women for fetal lung maturation and for the treatment of various maternal diseases. In this international multicentre randomized controlled trial, multiple courses of ACS (every 14 days) were not associated with maternal side effects, and the majority of women responded that they would participate in such a study again.

Multiple courses of antenatal corticosteroids for preterm birth study: 2-year outcomes

OBJECTIVE

The aim of this study was to determine the effects of repeated courses of prenatal corticosteroid therapy versus placebo on death or neurologic impairment among the children enrolled in the Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study, at 18 to 24 months of age.

METHODS

A total of 2305 infants were eligible for follow-up evaluation; 2104 infants (1069 in the prenatal corticosteroid therapy group and 1035 in the placebo group) were monitored. The primary outcome was death or neurologic impairment, defined as either cerebral palsy or cognitive delay, at 18 to 24 months of age. The secondary outcomes were measurements of growth (height, weight, and head circumference).

RESULTS

Children exposed to multiple courses of prenatal corticosteroid therapy had similar rates of death or neurologic impairment, compared with children exposed to placebo (148 children [13.8%] vs 142 children [13.7%]; odds ratio: 1.001[95% confidence interval: 0.75-1.30]; P = .95). They had a mean weight of 11.94 kg, compared with 12.14 kg in the placebo group (P = .04), a mean height of 85.51 cm, compared with 85.46 cm (P = .87), and a mean head circumference of 48.18 cm, compared with 48.25 cm (P = .45).

CONCLUSIONS

Multiple courses of prenatal corticosteroid therapy, given every 14 days, did not increase or decrease the risk of death or neurologic impairment at 18 to 24 months of age, compared with a single course of prenatal corticosteroid therapy. Continued follow-up monitoring of these children is necessary to assess neurobehavioral function, school performance, and possible susceptibility to disease.

Validity of autism diagnoses using administrative health data

It is necessary to monitor autism prevalence in order to plan education support and health services for affected children. This study was conducted to assess the accuracy of administrative health databases for autism diagnoses. Three administrative health databases from the province of Nova Scotia were used to identify diagnoses of autism spectrum disorders (ASD): the Hospital Discharge Abstract Database, the Medical Services Insurance Physician Billings Database and the Mental Health Outpatient Information System database. Seven algorithms were derived from combinations of requirements for single or multiple ASD claims from one or more of the three administrative databases. Diagnoses made by the Autism Team of the IWK Health Centre, using state-of-the-art autism diagnostic schedules, were compared with each algorithm, and the sensitivity, specificity and C-statistic (i.e. a measure of the discrimination ability of the model) were calculated. The algorithm with the best test characteristics was based on one ASD code in any of the three databases (sensitivity=69.3%). Sensitivity based on an ASD code in either the hospital or the physician billing databases was 62.5%. Administrative health databases are potentially a cost efficient source for conducting autism surveillance, especially when compared to methods involving the collection of new data. However, additional data sources are needed to improve the sensitivity and accuracy of identifying autism in Canada.

Multiple courses of antenatal corticosteroids for preterm birth (MACS): a randomised controlled trial

BACKGROUND

One course of antenatal corticosteroids reduces the risk of respiratory distress syndrome and neonatal death. Weekly doses given to women who remain undelivered after a single course may have benefits (less respiratory morbidity) or cause harm (reduced growth in utero). We aimed to find out whether multiple courses of antenatal corticosteroids would reduce neonatal morbidity and mortality without adversely affecting fetal growth.

METHODS

1858 women at 25-32 weeks' gestation who remained undelivered 14-21 days after an initial course of antenatal corticosteroids and continued to be at high risk of preterm birth were randomly assigned to multiple courses of antenatal corticosteroids (n=937) or placebo (n=921), every 14 days until week 33 or delivery, whichever came first. The primary outcome was a composite of perinatal or neonatal mortality, severe respiratory distress syndrome, intraventricular haemorrhage (grade III or IV), periventricular leucomalacia, bronchopulmonary dysplasia, or necrotising enterocolitis. Analysis was by intention to treat. All patients and caregivers were unaware of the treatment given. This trial is registered as number ISRCTN2654148.

FINDINGS

Infants exposed to multiple courses of antenatal corticosteroids had similar morbidity and mortality to those exposed to placebo (150 [12.9%] vs 143 [12.5%]). Those receiving multiple doses of corticosteroids also weighed less at birth than those exposed to placebo (2216 g vs 2330 g, p=0.0026), were shorter (44.5 cm vs 45.4 cm, p<0.001), and had a smaller head circumference (31.1 cm vs 31.7 cm, p<0.001).

INTERPRETATION

Multiple courses of antenatal corticosteroids, every 14 days, do not improve preterm-birth outcomes, and are associated with a decreased weight, length, and head circumference at birth. Therefore, this treatment schedule is not recommended.

FUNDING

Canadian Institutes of Health Research.

The impact of pregnancy on physical activity level

OBJECTIVE

The purpose of this study was to compare women's levels of physical activity during early pregnancy and during the year before pregnancy, and to identify characteristics associated with discontinuing sports and exercise among women previously active during the year before pregnancy.

METHODS

Data collected from 1,737 women enrolled in a prospective cohort study and who had no contraindications for exercise were included in this analysis. Measures of physical activity (including household and care-giving activities, active living and sports and exercise activities) during early pregnancy were compared to the year before pregnancy. Log binomial regression was used to identify factors associated with discontinuing sports and exercise during pregnancy.

RESULTS

There was a statistically significant decrease in all summary measures of physical activity during early pregnancy. The largest decreases were observed in sports and exercise activity. Among women active before pregnancy, age <35 years, multiparity, less than university education, pre-pregnancy body mass index (BMI) > or = 30 kg/m(2) and lower levels of pre-pregnancy exercise were associated with discontinuing sports and exercise activities during pregnancy.

CONCLUSION

Most women reduced their physical activity level during the first 20 weeks of pregnancy compared with their level of activity during the year prior to pregnancy, particularly for sports and exercise, although a small proportion of women in this study actually increased their activity in this area during early pregnancy. Participation in sports and exercise activity during pregnancy is potentially modifiable and could favorably impact perinatal health and maternal post-partum weight. The results of this study suggests that pregnancy is an event that leads to a decrease in physical activity.

Diabetes mellitus following gestational diabetes: role of subsequent pregnancy

OBJECTIVE

This study was designed to determine the rate of diabetes up to 13 years after pregnancies complicated by gestational diabetes and to identify risk factors for developing diabetes. The role of a subsequent pregnancy, with and without gestational diabetes, was also examined.

DESIGN

This was a retrospective cohort study of women with gestational diabetes.

POPULATION AND SETTING

Women who had gestational diabetes in their first pregnancy between 1989 and 2002 were identified through a population-based perinatal database in Nova Scotia, Canada.

METHODS

Subsequent diagnoses of diabetes, up to 13 years after the first pregnancy, were obtained from physician billing and hospital discharge databases. Cox proportional hazards regression models were used to estimate adjusted relative risks (RR) and 95% confidence intervals.

MAIN OUTCOME MEASURES

Diagnosis of diabetes after pregnancy.

RESULTS

Of the 1401 nulliparous women with gestational diabetes, 251 women (17.9%) developed diabetes in the follow-up period. The cumulative incidence at 1, 5, and 10 years was 5.9, 14.8, and 22.2%, respectively. Factors significantly associated with an increased risk of developing diabetes mellitus included a pre-pregnancy weight of > or = 86 kg (RR = 1.8, 95% CI 1.2-2.9), insulin therapy during the index pregnancy (RR = 4.1, 95% CI 2.1-7.9), neonatal hypoglycaemia (RR = 2.6, 95% CI 1.6-4.2), and a subsequent pregnancy with gestational diabetes (RR = 2.3, 95% CI 1.6-3.4).

CONCLUSION

Indicators of the severity of gestational diabetes, defined by insulin use, neonatal hypoglycaemia, and recurrent gestational diabetes in a subsequent pregnancy, are important in predicting a subsequent diagnosis of diabetes. Our findings do not support the theory that subsequent pregnancy, per se, increases the risk of developing diabetes.

Effect of homocysteine concentration in early pregnancy on gestational hypertensive disorders and other pregnancy outcomes

BACKGROUND

Increased total homocysteine (tHcy) may be associated with placental-mediated adverse pregnancy outcomes, but few prospective studies have measured tHcy before pregnancy outcome. This study was undertaken to determine whether increased tHcy measured in early pregnancy is associated with pregnancy loss, gestational hypertension (GH), preeclampsia, or small for gestational age (SGA) infants.

METHODS

We conducted a prospective cohort study between 2002 and 2005. We measured tHcy and serum folate in blood samples from pregnant women (<20 weeks' gestation) and collected detailed pregnancy information through a questionnaire and medical record review.

RESULTS

Of the 2119 women included in the study, 103 had a pregnancy loss, 115 had gestational hypertension, 65 had preeclampsia, and 129 had an SGA infant. Subjects with increased tHcy concentrations were at increased risk of pregnancy loss [relative risk (RR) 2.1, 95% CI 1.2-3.6] or preeclampsia (RR 2.7, 95% CI 1.4-5.0) than subjects with lower tHcy concentrations, but increased tHcy concentration was not associated with increased risk of developing GH or having an SGA infant.

CONCLUSION

The finding of high tHcy in early pregnancy as a risk factor for pregnancy loss and preeclampsia is consistent with a hypothesis that increased tHcy results in abnormalities of the placental vasculature.

Determinants of perinatal mortality and serious neonatal morbidity in the second twin

OBJECTIVE

To identify potential determinants of perinatal mortality and neonatal morbidity among second twins relative to first twins.

METHODS

A retrospective cohort design was used to study twin deliveries in Nova Scotia from 1988 to 2002. Monoamniotic or conjoined twins and twin pairs with major congenital anomaly or antepartum fetal death of either twin were excluded. The primary outcome was a composite measure of perinatal mortality and neonatal morbidity, including birth asphyxia, respiratory distress, neonatal trauma, and infection. Risk of adverse outcome of second twins relative to first-born co-twins was determined by matched-pair analysis.

RESULTS

Of 1,542 twin pairs, the second twin was at greater risk of composite adverse outcome (relative risk [RR] 1.62, 95% confidence interval [CI] 1.38-1.9) than the first twin. This excess risk was evident independent of presentation, chorionicity, or infant sex but was associated with planned vaginal delivery, birth weight discordance, and prolonged interdelivery interval. Term second twins were less likely to suffer excess morbidity with elective cesarean (RR 1.0, 95% CI 0.14-7.10) than with planned vaginal delivery (RR 3.0, 95% CI 1.47-6.11). The major contributors to neonatal morbidity in the second twin were birth asphyxia at 37 weeks or later and respiratory distress syndrome at less than 37 weeks.

CONCLUSION

The second twin is at greater risk of adverse perinatal outcome than the first twin, independent of presentation, chorionicity, or infant sex. Planned vaginal delivery, birth weight discordance, and prolonged interdelivery interval increase this infant risk. Elective cesarean delivery at term may improve perinatal outcome for the second twin. However, the number of cesarean births required to prevent one case of composite adverse outcome, assuming causality, was 33.

Stillbirth Risk Factors According to Timing of Exposure

PURPOSE

The purpose of the present study is to identify risk factors for stillbirth and explore hypotheses about the cause of stillbirth based on the time in gestation when exposures occur.

METHODS

Relationships between lifestyle factors, pregnancy conditions, medication use, and occupation on risk for stillbirth were examined within a population-based case-control study. Women who had a stillbirth and a random sample of women who had a live birth between 1999 and 2001 were identified through perinatal databases in Nova Scotia and Eastern Ontario, Canada. Exposure data were collected for each month of pregnancy and analyzed within trimesters. Case-control data were converted to case-cohort data, and hazard ratios (HRs) and 95% confidence intervals (CIs) were determined from Cox proportional hazards models.

RESULTS

This study included 105 stillbirth cases and 389 live-birth controls. Fertility treatment in the present pregnancy was associated with increased risk for stillbirth (adjusted HR, 4.0; 95% CI, 1.4-11.6). Smoking during the first trimester also was associated with increased risk for stillbirth (adjusted HR, 2.4; 95% CI, 1.2-4.9). Other risk factors included antiemetic use during the first trimester, second-trimester antibiotic use, low family income, and age older than 35 years.

CONCLUSIONS

Risk factors identified in this study concur with findings of previous studies and support the importance of early pregnancy exposures on stillbirth risk.