A Scoping Review of Risk Factors of Hypertensive Disorders of Pregnancy in Black Women Living in High-Income Countries: An Intersectional Approach

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are maternity-related increases in blood pressure (eg, gestational hypertension, preeclampsia, and eclampsia). Compared with women of other races in high-income countries, Black women have a comparatively higher risk of an HDP. Intersectionality helps to provide a deeper understanding of the multifactorial identities that affect health outcomes in this high-risk population.

OBJECTIVE

In this review, we sought to explore the literature on HDP risk factors in Black women living in high-income countries and to assess the interaction of these risk factors using the conceptual framework of intersectionality.

METHODS

We conducted this review using the Arksey and O'Malley methodology with enhancements from Levac and colleagues. Published articles in English on HDP risk factors with a sample of not less than 10% of Black women in high-income countries were included. Six databases, theses, and dissertations were searched from January 2000 to July 2021. A thematic analysis was used to summarize the results.

RESULTS

A final total of 36 studies were included from the 15 480 studies retrieved; 4 key themes of HDP risks were identified: (1) biological; (2) individual traditional; (3) race and ethnicity, geographical location, and immigration status; and (4) gender related. These intersectional HDP risk factors intersect to increase the risk of HDP among Black women living in high-income countries.

CONCLUSION

Upstream approaches are recommended to lower the risks of HDP in this population.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 7: Sex, Gender, and the Social Determinants of Health

Women vs men have major differences in terms of risk-factor profiles, social and environmental factors, clinical presentation, diagnosis, and treatment of cardiovascular disease. Women are more likely than men to experience health issues that are complex and multifactorial, often relating to disparities in access to care, risk-factor prevalence, sex-based biological differences, gender-related factors, and sociocultural factors. Furthermore, awareness of the intersectional nature and relationship of sociocultural determinants of health, including sex and gender factors, that influence access to care and health outcomes for women with cardiovascular disease remains elusive. This review summarizes literature that reports on under-recognized sex- and gender-related risk factors that intersect with psychosocial, economic, and cultural factors in the diagnosis, treatment, and outcomes of women's cardiovascular health.

Women's Knowledge of Future Cardiovascular Risk Associated With Complications of Pregnancy: A Systematic Review

Background

Several common pregnancy conditions significantly increase a woman's risk of future cardiovascular diseases (CVD). Patient education and interventions aimed at awareness and self-management of cardiovascular risk factors may help modify future cardiovascular risk. The aim of this systematic review was to examine education interventions for cardiovascular risk after pregnancy, clinical measures/scales, and knowledge outcomes in published qualitative and quantitative studies.

Methods

Five databases were searched (from inception to June 2023). Studies including interventions and validated and nonvalidated measures of awareness/knowledge of future cardiovascular risk among women after complications of pregnancy were considered. Quality was rated using the Mixed Methods Appraisal Tool. Results were analyzed using the Synthesis Without Meta-analysis reporting guideline. Characteristics of interventions were reported using the Template for Intervention Description and Replication. Fifteen studies were included; 3 were randomized controlled trials.

Results

In total, 1623 women had a recent or past diagnosis of hypertensive disorders of pregnancy, gestational diabetes mellitus, and/or premature birth. Of the 7 studies that used online surveys or questionnaires, 2 reported assessing psychometric properties of tools. Four studies used diverse educational interventions (pamphlets, information sheets, in-person group sessions, and an online platform with health coaching). Overall, women had a low level of knowledge about their future CVD risk. Interventions were effective in increasing this knowledge.

Conclusions

In conclusion, women have a low level of knowledge of risk of CVD after pregnancy complications. To increase this level of knowledge and self-management, this population has a strong need for psychometrically validated tailored education interventions.

Supporting self-management in women with pre-existing diabetes in pregnancy: a mixed-methods sequential comparative case study

INTRODUCTION

Maternal glycemia is associated with pregnancy outcomes. Thus, supporting the self-management experiences and preferences of pregnant women with type 1 and type 2 diabetes is crucial to optimize glucose control and perinatal outcomes.

RESEARCH DESIGN AND METHODS

This paper describes the mixed methods integration of a sequential comparative case study. The objectives are threefold, as we integrated the quantitative and qualitative data within the overall mixed methods design: (1) to determine the predictors of glycemic control during pregnancy; (2) to understand the experience and diabetes self-management support needs during pregnancy among women with pre-existing diabetes; (3) to assess how self-management and support experiences helpe to explain glycemic control among women with pre-existing diabetes in pregnancy. The purpose of the mixing was to integrate the quantitative and qualitative data to develop rich descriptive cases of how diabetes self-management and support experiences and preferences in women with type 1 and type 2 diabetes during pregnancy help explain glucose control. A narrative approach was used to weave together the statistics and themes and the quantitative results were integrated visually alongside the qualitative themes to display the data integration.

RESULTS

The quantitative results found that women achieved "at target" glucose control (mean A1C of the cohort by the third visit: 6.36% [95% Confidence Interval 6.11%, 6.60%]). The qualitative findings revealed that feelings of fear resulted in an isolating and mentally exhausting pregnancy. The quantitative data also indicated that women reported high levels of self-efficacy that increased throughout pregnancy. Qualitative data revealed that women who had worked hard to optimize glycemia during pregnancy were confident in their self-management. However, they lacked support from their healthcare team, particularly around self-management of diabetes during labour and delivery.

CONCLUSIONS

The achievement of optimal glycemia during pregnancy was motivated by fear of pregnancy complications and came at a cost to women's mental health. Mental health support, allowing women autonomy, and the provision of peer support may improve the experience of diabetes self-management during pregnancy. Future work should focus on developing, evaluating and implementing interventions that support these preferences.

Despite Increased Disease Activity, Women who Attended a Dedicated Inflammatory Bowel Disease and Pregnancy Clinic Had Infants With Higher Apgar Scores: A Population-Based Study

BACKGROUND

Attendance at a subspecialty pregnancy clinic for women with inflammatory bowel disease (IBD) improves disease-specific pregnancy knowledge. We examined the impact of attendance at a dedicated IBD-pregnancy clinic on IBD and perinatal outcomes.

METHODS

Using linked administrative databases in Alberta, Canada (2012-2019), we identified 1061 pregnant women with IBD who delivered singleton liveborn infants in-hospital who did (n = 314) and did not attend (n = 747) the clinic. Propensity score weighted multivariable log-binomial and multinomial logistic regression models were used to determine the risk of IBD and perinatal outcomes.

RESULTS

The median number of clinic visits was 3 (Q1-Q3, 3-5), with 34.7% completing a preconception consultation. A greater proportion of women who attended lived near the clinic, were nulliparous, had a disease flare prior to pregnancy, and were on maintenance IBD medication (P < .05). Women who attended had increased risks of a disease flare during pregnancy (adjusted risk ratio [aRR], 2.02; 95% CI, 1.45-2.82), an IBD-related emergency department visit during pregnancy (aRR, 2.66; 95% CI, 1.92-3.68), and cesarean delivery (aRR, 1.78; 95% CI, 1.23-2.57). Despite this, clinic attendees had a decreased risk of delivering an infant with a low Apgar score at 1 minute (risk ratio [RR], 0.49; 95% CI, 0.32-0.76) and 5 minutes (RR, 0.32; 95% CI, 0.12-0.87).

CONCLUSIONS

Women who attended a dedicated IBD-pregnancy clinic were more likely to have a disease flare prior to pregnancy, reflecting a more severe disease phenotype, but had similar perinatal outcomes and infants with better Apgar scores at birth. Our study suggests the value of these subspecialty clinics in providing enhanced IBD-specific prenatal care.

Trends and Self-Management Predictors of Glycemic Control During Pregnancy in Women With Preexisting Type 1 or Type 2 Diabetes: A Cohort Study

Background

Because much of diabetes management during pregnancy occurs at home, self-management factors such as self-efficacy, self-care activities, and care satisfaction may affect glycemia. Our objective was to explore trends in glycemic control during pregnancy in women with type 1 or type 2 diabetes; assess self-efficacy, self-care, and care satisfaction; and examine these factors as predictors of glycemic control.

Methods

We conducted a cohort study from April 2014 to November 2019 at a tertiary center in Ontario, Canada. Self-efficacy, self-care, care satisfaction, and A1C were measured three times during pregnancy (T1, T2, and T3). Linear mixed-effects modeling explored trends in A1C and examined self-efficacy, self-care, and care satisfaction as predictors of A1C.

Results

We recruited 111 women (55 with type 1 diabetes and 56 with type 2 diabetes). Mean A1C significantly decreased by 1.09% (95% CI -1.38 to -0.79) from T1 to T2 and by 1.14% (95% CI -1.43 to -0.86) from T1 to T3. Self-efficacy significantly predicted glycemic control for women with type 2 diabetes and was associated with a mean change in A1C of -0.22% (95% CI -0.42 to -0.02) per unit increase in scale. The exercise subscore of self-care significantly predicted glycemic control for women with type 1 diabetes and was associated with a mean change in A1C of -0.11% (95% CI -0.22 to -0.01) per unit increase in scale.

Conclusion

Self-efficacy significantly predicted A1C during pregnancy in a cohort of women with preexisting diabetes in Ontario, Canada. Future research will continue to explore the self-management needs and challenges in women with preexisting diabetes in pregnancy.

SmartMoms Canada: An evaluation of a mobile app intervention to support a healthy pregnancy

BACKGROUND

There is a lack of cost-effective and readily available access to evidence-based information to manage healthy behaviours for pregnant individuals. Mobile health (mHealth) tools offer a cost-effective, interactive, personalized option that can be delivered anywhere at a time most convenient for the user. This study protocol was primarily developed to, i) assess the feasibility of the SmartMoms Canada intervention in supporting participants to achieve gestational weight gain (GWG) guidelines. The secondary objectives are to, ii) assess user experience with the app, measured by adherence to the program via app software metrics and frequency of use, iii) determine the impact of SmartMoms Canada app usage on the adoption of healthful behaviours related to nutrition, physical activity and sleep habits, improvements in health-related quality of life, pregnancy-related complications, and symptoms of depression, and iv) investigate the potential extended effects of the app on postpartum health-related outcomes.

METHODS

This is a feasibility trial. Pregnant individuals aged 18-40 years with pre-gravid body mass index between 18.5 and 39.9 kg/m², carrying a singleton fetus, having Wi-Fi access, and at ≤20 weeks' gestation will be recruited. Eligible people will be followed from recruitment until 12 months postpartum.

DISCUSSION

SmartMoms Canada is the first bilingual Canadian-centric app designed for pregnant people. This mHealth intervention, with its ability to supply frequent interactions, provides pregnancy- related health knowledge to users, potentially leading to an improvement in pregnancy-related outcomes and behaviours, and, ultimately a reduction in the present economic burden related to in-person interventions.

TRIAL REGISTRATION

ISRCTN, ISRCTN16254958. Registered 20 December 2019, http://www.isrctn.com/ ISRCTN16254958.

Breastfeeding difficulties in the first 6 weeks postpartum among mothers with chronic conditions: a latent class analysis

BACKGROUND

Breastfeeding difficulties frequently exacerbate one another and are common reasons for curtailed breastfeeding. Women with chronic conditions are at high risk of early breastfeeding cessation, yet limited evidence exists on the breastfeeding difficulties that co-occur in these mothers. The objective of this study was to explore clusters of breastfeeding difficulties experienced up to 6 weeks postpartum among mothers with chronic conditions and to examine associations between chronic condition types and breastfeeding difficulty clusters.

METHODS

We analyzed 348 mothers with chronic conditions enrolled in a prospective, community-based pregnancy cohort study from Alberta, Canada. Data were collected through self-report questionnaires. We used latent class analysis to identify clusters of early breastfeeding difficulties and multinomial logistic regression to examine whether types of chronic conditions were associated with these clusters, adjusting for maternal and obstetric factors.

RESULTS

We identified three clusters of breastfeeding difficulties. The "physiologically expected" cluster (51.1% of women) was characterized by leaking breasts and engorgement (reference outcome group); the "low milk production" cluster (15.4%) was discerned by low milk supply and infant weight concerns; and the "ineffective latch" cluster (33.5%) involved latch problems, sore nipples, and difficulty with positioning. Endocrine (adjusted relative risk ratio [RRR] 2.34, 95% CI 1.10-5.00), cardiovascular (adjusted RRR 2.75, 95% CI 1.01-7.81), and gastrointestinal (adjusted RRR 2.51, 95% CI 1.11-5.69) conditions were associated with the low milk production cluster, and gastrointestinal (adjusted RRR 2.44, 95% CI 1.25-4.77) conditions were additionally associated with the ineffective latch cluster.

CONCLUSION

Half of women with chronic conditions experienced clusters of breastfeeding difficulties corresponding either to low milk production or to ineffective latch in the first 6 weeks postpartum. Associations with chronic condition types suggest that connections between lactation physiology and disease pathophysiology should be considered when providing breastfeeding support.

Patient-reported Benefits and Limitations of Mobile Health Technologies for Diabetes in Pregnancy: A Scoping Review

OBJECTIVES

For women with pre-existing and gestational diabetes, pregnancy involves specialized and intensive medical care to optimize maternal and infant outcomes. Medical management for patients with diabetes in pregnancy typically occurs via frequent face-to-face outpatient appointments. COVID-19-induced barriers to face-to-face care have identified the need for high-quality, patient-centred virtual health-care modalities, such as mobile health (mHealth) technologies. Our aim in this review was to identify the patient-reported benefits and limitations of mHealth technologies among women with diabetes in pregnancy. We also aimed to determine how the women's experiences aligned with the best practice standards for patient-centred communication.

METHODS

The framework presented by Arksey and O'Malley for conducting scoping reviews, with refinements by Levac et al, was used to guide this review. Relevant studies were identified through comprehensive database searches of MEDLINE, Embase, Emcare and PsycINFO. Thomas and Harden's methods for the thematic synthesis of qualitative research in systematic reviews guided the synthesis of patient-reported benefits and limitations of mHealth technology.

RESULTS

Overall, 19 studies describing the use of 16 unique mHealth technologies among 742 women were included in the final review. Patient-reported benefits of mHealth included convenience, support of psychosocial well-being and facilitation of diabetes self-management. Patient-reported limitations included lack of important technological features, perceived burdensome aspects of mHealth and lack of trust in virtual health care.

CONCLUSIONS

Women with diabetes report some benefits from mHealth use during pregnancy. Codesigning future technologies with end users may help address the perceived limitations and effectiveness of mHealth technologies.

Supporting self-management in women with pre-existing diabetes in pregnancy: a protocol for a mixed-methods sequential comparative case study

INTRODUCTION

For women with pre-existing type 1 and type 2 diabetes, glycaemic targets are narrow during the preconception and prenatal periods to optimise pregnancy outcomes. Women aim to achieve glycaemic targets during pregnancy through the daily tasks of diabetes self-management. Diabetes self-management during pregnancy involves frequent self-monitoring of blood glucose and titration of insulin based on glucose measures and carbohydrate intake. Our objective is to explore how self-management and support experiences help explain glycaemic control among women with pre-existing diabetes in pregnancy.

METHODS AND ANALYSIS

We will conduct a four-phased mixed-methods sequential comparative case study. Phase I will analyse the data from a prospective cohort study to determine the predictors of glycaemic control during pregnancy related to diabetes self-management among women with pre-existing diabetes. In phase II, we will use the results of the cohort analysis to develop data collection tools for phase III. Phase III will be a qualitative description study to understand women's diabetes education and support needs during pregnancy. In phase IV, we will integrate the results of phases I and III to generate unique cases representing the ways in which self-management and support experiences explain glycaemic control in pregnancy.

ETHICS AND DISSEMINATION

The phase I cohort study received approval from our local ethics review board, the Hamilton Integrated Ethics Review Board. We will seek ethics approval for the phase III qualitative study prior to its commencement. Participants will provide informed consent before study enrolment. We plan to publish our results in peer-reviewed journals and present our findings to stakeholders at relevant conferences/symposia.

Exploring weight bias internalization in pregnancy

Background

Recent research has shown that pregnant individuals experience weight stigma throughout gestation, including negative comments and judgement associated with gestational weight gain (GWG). Weight bias internalization (WBI) is often a result of exposure to weight stigma and is detrimental to biopsychological health outcomes. The purpose of this study was to explore WBI in pregnancy and compare scores based on maternal weight-related factors including pre-pregnancy body mass index (BMI), obesity diagnosis and excessive GWG.

Methods

Pregnant individuals in Canada and USA completed a modified version of the Adult Weight Bias Internalization Scale. Self-reported pre-pregnancy height and weight were collected to calculate and classify pre-pregnancy BMI. Current weight was also reported to calculate GWG, which was then classified as excessive or not based on Institute of Medicine (2009) guidelines. Participants indicated if they were diagnosed with obesity by a healthcare provider. Inferential analyses were performed comparing WBI scores according to pre-pregnancy BMI, excessive GWG, and obesity diagnosis. Significance was accepted as p < 0.05 and effect sizes accompanied all analyses.

Result

336 pregnant individuals completed the survey, with an average WBI score of 3.9 ± 1.2. WBI was higher among those who had a pre-pregnancy BMI of obese than normal weight (p = 0.04, η² = 0.03), diagnosed with obesity than not diagnosed (p < 0.001, Cohen’s d = 1.3), and gained excessively versus not (p < 0.001, Cohen’s d = 1.2).

Conclusions

Pregnant individuals who have a higher BMI, obesity and gain excessively may experience WBI. Given that weight stigma frequently occurs in pregnancy, effective person-oriented strategies are needed to mitigate stigma and prevent and care for WBI.

Development and Internal Validation of a Risk Prediction Model for Acute Cardiovascular Morbidity in Preeclampsia

BACKGROUND

Persons with preeclampsia are at increased short-term risk of adverse cardiovascular outcomes during pregnancy and the early postpartum period. We aimed to develop and internally validate a risk assessment tool to predict acute cardiovascular morbidity in preeclampsia.

METHODS

The study was conducted at an academic obstetric hospital. Participants with preeclampsia at delivery between 2007 and 2017 were included. A model to predict acute cardiovascular morbidity at delivery and within 6 weeks postpartum was developed and evaluated. The primary composite outcome included pulmonary edema/acute heart failure, myocardial infarction, aneurysm, cardiac arrest/ventricular fibrillation, heart failure/arrest during surgery or procedure, cerebrovascular disorders, cardiogenic shock, conversion of cardiac rhythm, and difficult-to-control severe hypertension. We assessed model discrimination and calibration. We used bootstrapping for internal validation.

RESULTS

4,171 participants with preeclampsia were included. The final model comprised 8 variables. Predictors positively associated with acute cardiovascular morbidity (presented as odds ratio [OR] with 95% confidence interval [CI]) were: gestational age at delivery (20-36 weeks 5.36 [3.67, 7.82]; 37-38 weeks 1.75 [1.16, 2.64]), maternal age (≥40 years 1.65 [1.00, 2.72]; 35-39 years 1.49 [1.07, 2.09]), and prior cesarean delivery (1.47, [1.01, 2.13]). The model had an area under the receiver operating characteristic curve of 0.72 (95% CI [0.69, 0.74]). Moreover, it was adequately calibrated and performed well on internal validation.

CONCLUSIONS

This risk prediction tool identified women with preeclampsia at highest risk of acute cardiovascular morbidity. If externally validated, this tool may facilitate early interventions aimed at preventing adverse cardiovascular outcomes in pregnancy and postpartum.

Connecting the Dots: Structural Racism, Intersectionality, and Cardiovascular Health Outcomes for African, Caribbean, and Black Mothers

African, Caribbean, and Black (ACB) women globally experience health inequities that impact on their cardiovascular health outcomes during the perinatal period, and for years after. Aside from being at a high risk of having and dying from hypertensive disorders of pregnancy, ACB women who survive face a lifelong risk of cardiovascular disease years after the diagnosis. Racism as a determinant of health intersects with gender, societal structures, and immigration status to contribute to cardiovascular health and access to quality health care services for ACB women. Equitable policies and culturally appropriate programs are needed to improve the cardiovascular health of ACB women.

Directive clinique no 426 : Troubles hypertensifs de la grossesse : Diagnostic, prédiction, prévention et prise en charge

OBJECTIF

La présente directive a été élaborée par des fournisseurs de soins de maternité en obstétrique et en médecine interne. Elle aborde le diagnostic, l'évaluation et la prise en charge des troubles hypertensifs de la grossesse, la prédiction et la prévention de la prééclampsie ainsi que les soins post-partum des femmes avec antécédent de trouble hypertensif de la grossesse.

POPULATION CIBLE

Femmes enceintes. BéNéFICES, RISQUES ET COûTS: La mise en œuvre des recommandations de la présente directive devrait réduire l'incidence des troubles hypertensifs de la grossesse, en particulier la prééclampsie, et des issues défavorables associées. DONNéES PROBANTES: La revue exhaustive de la littérature a été mise à jour en tenant compte des nouvelles données probantes jusqu'en décembre 2020 et en suivant la même méthodologie que pour la précédente directive de la Société des obstétriciens et gynécologues du Canada (SOGC) sur les troubles hypertensifs de la grossesse. La recherche s'est limitée aux articles publiés en anglais ou en français. Les recommandations relatives aux traitements s'appuient d'abord sur les essais cliniques randomisés et les revues systématiques (lorsque disponibles), ainsi que sur l'évaluation des résultats cliniques substantiels chez les mères et les bébés. MéTHODES DE VALIDATION: Les auteurs se sont entendus sur le contenu et les recommandations par consensus et ont répondu à l'examen par les pairs du comité de médecine fœto-maternelle de la SOGC. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE) et se sont gardé l'option de désigner certaines recommandations par la mention « bonne pratique ». Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). Le conseil d'administration de la SOGC a approuvé la version définitive aux fins de publication.

PROFESSIONNELS CIBLES

Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières et anesthésistes) qui prodiguent des soins aux femmes avant, pendant ou après la grossesse.

RECOMMANDATIONS

Guideline No. 426: Hypertensive Disorders of Pregnancy: Diagnosis, Prediction, Prevention, and Management

OBJECTIVE

This guideline was developed by maternity care providers from obstetrics and internal medicine. It reviews the diagnosis, evaluation, and management of the hypertensive disorders of pregnancy (HDPs), the prediction and prevention of preeclampsia, and the postpartum care of women with a previous HDP.

TARGET POPULATION

Pregnant women.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in these guidelines may reduce the incidence of the HDPs, particularly preeclampsia, and associated adverse outcomes.

EVIDENCE

A comprehensive literature review was updated to December 2020, following the same methods as for previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines, and references were restricted to English or French. To support recommendations for therapies, we prioritized randomized controlled trials and systematic reviews (if available), and evaluated substantive clinical outcomes for mothers and babies.

VALIDATION METHODS

The authors agreed on the content and recommendations through consensus and responded to peer review by the SOGC Maternal Fetal Medicine Committee. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, along with the option of designating a recommendation as a "good practice point." See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).The Board of the SOGC approved the final draft for publication.

INTENDED USERS

All health care providers (obstetricians, family doctors, midwives, nurses, and anesthesiologists) who provide care to women before, during, or after pregnancy.

RECOMMENDATIONS

Sex influences the effect of adiposity on arterial stiffness and renin‐angiotensin aldosterone system activity in young adults

Introduction

Methods

Results

Conclusion

Healthcare workers' perception of gender and work roles during the COVID-19 pandemic: a mixed-methods study

OBJECTIVES

A high functioning healthcare workforce is a key priority during the COVID-19 pandemic. We sought to determine how work and mental health for healthcare workers changed during the COVID-19 pandemic in a universal healthcare system, stratified by gender factors.

DESIGN

A mixed-methods study was employed. Phase 1 was an anonymous, internet-based survey (7 May-15 July 2020). Phase 2 was semistructured interviews offered to all respondents upon survey completion to describe how experiences may have differed by gender identity, roles and relations.

SETTING

National universal healthcare system (Canada).

PARTICIPANTS

2058 Canadian healthcare worker survey respondents (87% women, 11% men, 1% transgender or Two-Spirit), including 783 health professionals, 673 allied health professionals, 557 health support staff. Of the 63 unique healthcare worker types reported, registered nurses (11.5%), physicians (9.9%) and pharmacists (4.5%) were most common. Forty-six healthcare workers were interviewed.

MAIN OUTCOME MEASURES

Reported pandemic-induced changes to occupational leadership roles and responsibilities, household and caregiving responsibilities, and anxiety levels by gender identity.

RESULTS

Men (19.8%) were more likely to hold pandemic leadership roles compared with women (13.4%). Women (57.5%) were more likely to report increased domestic responsibilities than men (45%). Women and those with dependents under the age of 10 years reported the greatest levels of anxiety during the pandemic. Interviews with healthcare workers further revealed a perceived imbalance in leadership opportunities based on gender identity, a lack of workplace supports disproportionately affecting women and an increase in domestic responsibilities influenced by gender roles.

CONCLUSIONS

The COVID-19 pandemic response has important gendered effects on the healthcare workforce. Healthcare workers are central to effective pandemic control, highlighting an urgent need for a gender-transformative pandemic response strategy.

Depressed mood and anxiety as risk factors for hypertensive disorders of pregnancy: a systematic review and meta-analysis

BACKGROUND

Psychosocial factors have been implicated as both a cause and consequence of hypertension in the general population but are less understood in relation to hypertensive disorders of pregnancy (HDP). The aims of this review were to (1) synthesize the existing literature examining associations between depression and/or anxiety in pregnancy and HDP and (2) assess if depression and/or anxiety in early pregnancy was a risk factor for HDP.

METHODS

A comprehensive search of Medline, Embase, CINAHL, and PsycINFO was conducted from inception to March 2020 using terms related to 'pregnancy', 'anxiety', 'depression', and 'hypertensive disorders'. English-language cohort and case-control studies were included if they reported: (a) the presence or absence of clinically significant symptoms of depression/anxiety, or a medical record diagnosis of depression or an anxiety disorder in pregnancy; (b) diagnosis of HDP; and/or (c) data comparing the depressed/anxious group to the non-depressed/anxious group on HDP. Data related to depression/anxiety, HDP, study characteristics, and aspects related to study quality were extracted independently by two reviewers. Random-effects meta-analyses of estimated pooled relative risks (RRs) were conducted for depression/anxiety in pregnancy and HDP.

RESULTS

In total, 6291 citations were retrieved, and 44 studies were included across 61.2 million pregnancies. Depression and/or anxiety were associated with HDP [RR = 1.39; 95% confidence interval (CI) 1.25-1.54].

CONCLUSIONS

When measurement of anxiety or depression preceded diagnosis of hypertension, the association remained (RR = 1.27; 95% CI 1.07-1.50). Women experiencing depression or anxiety in pregnancy have an increased prevalence of HDP compared to their non-depressed or non-anxious counterparts.

Age-period-cohort effects in pre-existing and pregnancy-associated diseases amongst primiparous women

BACKGROUND

The average age at first birth is steadily increasing in developed countries; however, demographic shifts in maternal age at childbearing have not occurred in isolation. While temporal increases in adverse pregnancy outcomes are typically attributed to increases in maternal age, little is known about how maternal health status has changed across maternal age, period of delivery, and birth cohort.

METHODS

Natality files were used to identify primiparous women delivering liveborn, singleton infants in the USA in 1989, 1994, 1999, 2004, 2009, and 2014 (n = 6,857,185). Age-period-cohort models using the intrinsic estimator adjusted for temporal trends in smoking and gestational weight gain were used to quantify temporal changes in the rates of pre-existing (chronic hypertension, pre-existing diabetes) and pregnancy-associated (pregnancy-associated hypertension, gestational diabetes, eclampsia) diseases. Log-linear models were used to model the impact of temporal changes on preterm birth, small, and large for gestational age (SGA/LGA) births.

RESULTS

Significant period effects resulted in temporal increases in the rate of chronic hypertension, pregnancy-associated hypertension, and gestational diabetes, and a significant decrease in the rate of eclampsia. These observed period effects were associated with a 10.6% increase in the rate of SGA and a 7.1% decrease in LGA. Had the rate of pre-existing and pregnancy-associated diseases remained static over this time period, the rate of preterm birth would have increased by 5.9%, but instead only increased by 4.4%.

CONCLUSIONS

Independent of changes in the incidence of pre-existing and pregnancy-associated diseases as women age, the obstetric population is becoming less healthy over time. This is important, as these changes have a direct negative impact on short-term obstetric outcomes and women's long-term health.

The impact of occupational activities during pregnancy on pregnancy outcomes: a systematic review and metaanalysis

OBJECTIVE

Data: An increasing number of studies suggest that exposure to physically demanding work during pregnancy could be associated with increased risks of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. The purpose of this study was to examine the influence of occupational activities during pregnancy on maternal and fetal health outcomes.

STUDY

Studies of all designs (except case studies and reviews) that contained information on the relevant population (women who engaged in paid work during pregnancy), occupational exposures (heavy lifting, prolonged standing, prolonged walking, prolonged bending, and heavy physical workload), comparator (no exposure to the listed physical work demands), and outcomes (preterm birth, low birthweight, small for gestational age, miscarriage, gestational hypertension, preeclampsia, gestational diabetes mellitus, stillbirth, and intrauterine growth restriction) were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Five electronic databases and 3 gray literature sources were searched up to March 15, 2019.

RESULTS

Eighty observational studies (N=853,149) were included. Low-to-very low certainty evidence revealed that lifting objects ≥11 kg was associated with an increased odds ratio of miscarriage (odds ratio, 1.31; 95% confidence interval, 1.08-1.58; I²=79%), and preeclampsia (odds ratio, 1.35; 95% confidence interval, 1.07-1.71; I²=0%). Lifting objects for a combined weight of ≥100 kg per day was associated with an increased odds of preterm delivery (odds ratio, 1.31; 95% confidence interval, 1.11-1.56; I²=0%) and having a low birthweight neonate (odds ratio, 2.08; 95% confidence interval, 1.06-4.11; I²=73%). Prolonged standing was associated with increased odds of preterm delivery (odds ratio, 1.11; 95% confidence interval, 1.02-1.22; I²=30%) and having a small-for-gestational-age neonate (odds ratio, 1.17; 95% confidence interval, 1.01-1.35; I²=41%). A heavy physical workload was associated with increased odds of preterm delivery (odds ratio, 1.23; 95% confidence interval, 1.07-1.41; I²=32%) and having a low birthweight neonate (odds ratio, 1.79; 95% confidence interval, 1.11-2.87; I²=87%). All other associations were not statistically significant. Dose-response analysis showed women stand for >2.5 hours per day (vs no standing) had a 10% increase in the odds of having a preterm delivery.

CONCLUSION

Physically demanding work during pregnancy is associated with an increased risk of adverse pregnancy outcomes.

Postpartum hypertensive disorders in the Emergency Department - A retrospective review of local practice in Calgary, Alberta

Hypertensive disorders of pregnancy (HDP) commonly occur postpartum and are associated with preventable maternal morbidity and mortality. HDP is the most common reason for presentation to the Emergency Department (ED) after delivery. However, given the broad range of non-specific symptoms, recognition and management of postpartum HDP may be delayed leading to serious adverse clinical outcomes.

OBJECTIVES

To describe: (1) the clinical presentation; (2) ED physician's diagnosis; and (3) current ED management of women with HDP in Calgary ED's.

METHODS

A retrospective review of postpartum women (within 42 days of delivery) attending three Calgary EDs between 2011 and 2012 was performed. Administrative data was used to randomly select 119 women; 44 with diagnostic codes for any HDP (labeled "HDP") and 75 with diagnostic codes for related diagnoses (e.g., abdominal pain, headache) (labeled "non-HDP"). Charts were reviewed for: maternal demographics; obstetrical history; and ED clinical findings, investigations and management.

RESULTS

Maternal characteristics were similar between groups. There was considerable overlap in clinical presentation between groups, with no significant difference for any presenting symptom. Only 52.3% (CI 40.0-64.3%) of women in the "HDP" group had HDP investigations (bloodwork and urinalysis) vs. 30.4% (CI 18.7-58.5%) of "non-HDP" (p = 0.072). HDP was diagnosed by the ED team in 42.9% (CI 31.1-55.5%) of the HDP group of whom only 40.3% (CI 28.7-53.1) received antihypertensive therapy.

CONCLUSIONS

Postpartum HDP is commonly under-recognized and under-treated in the ED, highlighting opportunities for interventions to improve the recognition and management of postpartum HDP.

Cardiovascular Disease-Related Morbidity and Mortality in Women With a History of Pregnancy Complications

BACKGROUND

Women with a history of certain pregnancy complications are at higher risk for cardiovascular (CVD) disease. However, most clinical guidelines only recommend postpartum follow-up of those with a history of preeclampsia, gestational diabetes mellitus, or preterm birth. This systematic review was undertaken to determine if there is an association between a broader array of pregnancy complications and the future risk of CVD.

METHODS

We systematically searched PubMed, MEDLINE and EMBASE (via Ovid), CINAHL, and the Cochrane Library from inception to September 22, 2017, for observational studies of the association between the hypertensive disorders of pregnancy, placental abruption, preterm birth, gestational diabetes mellitus, low birth weight, small-for-gestational-age birth, stillbirth, and miscarriage and subsequent CVD. Likelihood ratio meta-analyses were performed to generate pooled odds ratios (OR) and 95% intrinsic confidence intervals (ICI).

RESULTS

Our systematic review included 84 studies (28 993 438 patients). Sample sizes varied from 250 to 2 000 000, with a median follow-up of 7.5 years postpartum. The risk of CVD was highest in women with gestational hypertension (OR 1.7; 95% ICI, 1.3-2.2), preeclampsia (OR 2.7; 95% ICI, 2.5-3.0), placental abruption (OR 1.8; 95% ICI, 1.4-2.3), preterm birth (OR 1.6; 95% ICI, 1.4-1.9), gestational diabetes mellitus (OR 1.7; 95% ICI, 1.1-2.5), and stillbirth (OR 1.5; 95% ICI, 1.1-2.1). A consistent trend was seen for low birth weight and small-for-gestational-age birth weight but not for miscarriage.

CONCLUSIONS

Women with a broader array of pregnancy complications, including placental abruption and stillbirth, are at increased risk of future CVD. The findings support the need for assessment and risk factor management beyond the postpartum period.

The impact of occupational shift work and working hours during pregnancy on health outcomes: a systematic review and meta-analysis

BACKGROUD

An increasing number of original studies suggest that exposure to shift work and long working hours during pregnancy could be associated with the risk of adverse pregnancy outcomes, but the results remain conflicting and inconclusive.

OBJECTIVE

To examine the influences of shift work and longer working hours during pregnancy on maternal and fetal health outcomes.

DATA SOURCES

Five electronic databases and 3 gray literature sources were searched up to March 15, 2019.

METHODS OF STUDY SELECTION

Studies of all designs (except case studies and reviews) were included, which contained information on the relevant population (women who engaged in paid work during pregnancy); exposure (rotating shift work [shifts change according to a set schedule], fixed night shift [typical working period is between 11:00 pm and 11:00 am] or longer working hours [>40 hours per week]);comparator (fixed day shift [typical working period is between 8:00 am and 6:00 pm] or standard working hours [≤40 hours per week]); and outcomes (preterm delivery, low birthweight [birthweight <2500 g], small for gestational age, miscarriage, gestational hypertension, preeclampsia, intrauterine growth restriction, stillbirth, and gestational diabetes mellitus).

TABULATION, INTEGRATION, AND RESULTS

From 3305 unique citations, 62 observational studies (196,989 women) were included. "Low" to "very low" certainty evidence from these studies revealed that working rotating shifts was associated with an increased odds of preterm delivery (odds ratio, 1.13; 95% confidence interval, 1.00-1.28, I² = 31%), an infant small for gestational age (odds ratio, 1.18, 95% confidence interval, 1.01-1.38, I² = 0%), preeclampsia (odds ratio, 1.75, 95% confidence interval, 1.01-3.01, I² = 75%), and gestational hypertension (odds ratio, 1.19, 95% confidence interval, 1.10-1.29, I² = 0%), compared to those who worked a fixed day shift. Working fixed night shifts was associated with an increased odds of preterm delivery (odds ratio, 1.21; 95% confidence interval, 1.03-1.42; I² = 36%) and miscarriage (odds ratio, 1.23; 95% confidence interval, 1.03-1.47; I² = 37%). Compared with standard hours, working longer hours was associated with an increased odds of miscarriage (odds ratio, 1.38; 95% confidence interval, 1.08-1.77; I² = 73%), preterm delivery (odds ratio, 1.21; 95% confidence interval, 1.11-1.33; I² = 30%), an infant of low birthweight (odds ratio, 1.43; 95% confidence interval, 1.11-1.84; I² = 0%), or an infant small for gestational age (odds ratio, 1.16, 95% confidence interval, 1.00-1.36, I² = 57%). Dose-response analysis showed that women working more than 55.5 hours (vs 40 hours) per week had a 10% increase in the odds of having a preterm delivery.

CONCLUSION

Pregnant women who work rotating shifts, fixed night shifts, or longer hours have an increased risk of adverse pregnancy outcomes.

Abstract P1101: Hormonal Contraceptive Use, Arterial Stiffness and Renin Angiotensin System Activity in Women

Background: Oral contraceptive use is associated with increased CV risk. Whether non-oral hormonal contraceptive use poses a similar risk is unclear.

Objectives: To evaluate the association between oral and non-oral hormonal and arterial stiffness and renin-angiotensin system (RAS) activity in premenopausal women.

Methods: Healthy premenopausal women using non-oral hormonal contraception (NOHC), oral hormonal contraception (OC) (minimum duration of 3 months) and controls were studied in a fasting, high-salt state. Aortic augmentation index (AIx) and pulse wave velocity (PWV) were measured at baseline and in response to Angiotensin II (AngII) challenge, a validated marker of arterial RAS activity. Results from the 3 groups were compared using ANOVA and presented as mean and standard error.

Results: Fifty-six women (6 OC, 8 NOHC, 42 controls) were studied. Women were similar in age (OC 29±7yvs NOHC 28±4yvs controls 32±2y, p=0.52)and BMI (OC 26.7±1vsNOHC 22.3±2vs controls25.3±4, p=0.12). No differences were observed amongst the groups with regards to baseline arterial stiffness measures (AIx: OC 4.08±1%; NOHC -2.75±2%; controls 9.01±3%; p =0.10; PWV: OC 6.94±3 m/s; NOHC 6.4±2 m/s; controls 8.04±5m/s; p=0.49). In response to AngII challenge, NOHC users had a greater change in AIx compared to OC after adjustment for age and blood pressure (NOHC 17.06±3%; controls 9.76±1%; p=0.048). No significant changes in PWV were observed among NOHC or OC and controls.

Conclusions: Arterial RAS is lower in non-oral hormonal contraceptive users, suggesting this may be a safer contraception option in women at high risk of CVD.

Abstract 031: Association Between Non-Oral Hormonal Contraceptives and Blood Pressure: A Systematic Review

Background: Combined oral contraceptives (COCs) are associated with increased blood pressure (BP) and hypertension. Whether non-oral forms of hormonal contraceptive (NOHC) have similar associations is unknown.

Methods: We conducted a systematic review investigating the association between NOHC use and blood pressure compared to women using COC and non-hormonal contraception (NHC). Three databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) were searched for articles published from database inception through October 2018. Primary studies examining women using NOHC [transdermal, hormonal intrauterine device (IUD), implant, vaginal ring or injectables] compared with women using COC or NHC were included. Two independent investigators screened identified abstracts. Data on study population, hormonal exposure, outcomes, study quality and risk of bias were independently extracted from each eligible study. Primary outcomes were change in BP or prevalence of hypertension. Quality of case control and cohort studies was assessed using the Newcastle-Ottawa scale. Quality of randomized control trials was assessed using the Cochrane risk of bias tool.

Results: Of 3981 studies reviewed, 22 met inclusion criteria (12 studies on injectables, 6 on implants, 4 on hormonal IUDs, 3 on the vaginal ring). Some studies examining the effect of IUD use showed a significantly lower BP compared to COC use, and no difference compared to NHC users. No differences in BP were reported with vaginal ring use compared to COC or NHC use. Conflicting results were presented with implant use compared to NHC use, but no change in BP compared to COC. Five studies reported increased BP with injectable use compared to COC and NHC, while seven studies showed no change in BP. All women remained in the normotensive range in all included studies.

Conclusion: Non-oral hormonal contraceptive use is associated with increases in blood pressure, though the effects differ by route of administration. These results may inform contraceptive choices in women with or at risk of hypertension.

Point of Care (POC) Influenza Immunization for Pregnant Women, Calgary Zone, Alberta Health Services

IntroductionVaccinating pregnant patients for neonatal protection needs to be integrated into prenatal care as new vaccines emerge. Uptake of influenza vaccine, universally recommended in pregnancy, is low. Immunization was offered and administered to pregnant women at point of care (POC) during two flu seasons at an urban tertiary care center. Objectives and ApproachPrimary objective is to determine if POC impacts immunization rate during flu season among a cohort of pregnant women by location and gestational age. Secondary objectives are to examine the pattern of influenza-like illnesses (ILI) among vaccinated and unvaccinated women, and to describe pilot outcomes of POC. Four consecutive influenza seasons (2014/2015, 2015/2016, 2016/2017, 2017/2018) will be examined using seven databases: a) Clinibase, b) National Ambulatory Care Reporting System; C) Discharge Abstract Database; d) Physician Claims; e) Alberta Perinatal Health Program; f) Calgary Zone Public Health; and g) Pharmaceutical Information Network. Outcomes will be examined descriptively using frequencies and proportions. ResultsBased on the preliminary analysis, approximately 10, 000 visits among 2,500 women occurred during each flu season at the four obstetric care locations: two outpatient clinics and two inpatient units. The proportion of pregnant women who received the flu vaccine ranged from 15-21% during the first three flu seasons. Majority of the women received the vaccine at the flu campaigns (range 48-67%), followed by pharmacy (20-32%). For the 2017-2018 season, year to date uptake rates in outpatient clinics are significantly higher. Final results on additional outcomes will be available by September 2018. Conclusion/ImplicationsIn completing this study, we hope to better understand the patterns of immunization uptake in pregnancy by place of immunization and gestational age, i.e. identifying optimal “window of opportunity”. Results will inform the infrastructure needed to collect data on vaccines administered during pregnancy and linkage to maternal and infant outcomes.

Canadian Stroke Best Practice Consensus Statement: Acute Stroke Management during pregnancy

The Canadian Stroke Best Practice Consensus Statement Acute Stroke Management during Pregnancy is the second of a two-part series devoted to stroke in pregnancy. The first part focused on the unique aspects of secondary stroke prevention in a woman with a prior history of stroke who is, or is planning to become, pregnant. This document focuses on the management of a woman who experiences an acute stroke during pregnancy. This consensus statement was developed in recognition of the need for a specifically tailored approach to the management of this group of patients in the absence of any broad-based, stroke-specific guidelines or consensus statements, which do not exist currently. The foundation for the development of this document was the concept that maternal health is vital for fetal well-being; therefore, management decisions should be based first on the confluence of two clinical considerations: (a) decisions that would be made if the patient wasn't pregnant and (b) decisions that would be made if the patient hadn't had a stroke, then nuanced as needed. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include initial emergency management, diagnostic imaging, acute stroke treatment, the management of hemorrhagic stroke, anesthetic management, post stroke management for women with a stroke in pregnancy, intrapartum considerations, and postpartum management. These statements are appropriate for healthcare professionals across all disciplines and system planners to ensure pregnant women who experience a stroke have timely access to both expert neurological and obstetric care.

Canadian stroke best practice consensus statement: Secondary stroke prevention during pregnancy

The Canadian Stroke Best Practice Consensus Statement: Secondary Stroke Prevention during Pregnancy, is the first of a two-part series devoted to stroke in pregnancy. This document focuses on unique aspects of secondary stroke prevention in a woman with a prior history of stroke or transient ischemic attack who is, or is planning to become, pregnant. Although stroke is relatively rare in this cohort, several aspects of pregnancy can increase stroke risk during or immediately after pregnancy. The rationale for the development of this consensus statement is based on the premise that stroke in this group requires a specifically-tailored management approach. No other broad-based, stroke-specific guidelines or consensus statements exist currently. Underpinning the development of this document was the concept that maternal health is vital for fetal wellbeing; therefore, management decisions should be based on the confluence of two clinical considerations: (a) decisions that would be made if the patient was not pregnant and (b) decisions that would be made if the patient had not had a stroke. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include general management considerations for secondary stroke prevention, the use of antithrombotics, blood pressure management, lipid management, diabetes care, and management for specific ischemic stroke etiologies in pregnancy. The focus is on maternal and fetal health while minimizing risks of a recurrent stroke, through counseling, monitoring, and the safety of select pharmacotherapy. These statements are appropriate for health care professionals across all disciplines.

The effect and safety of postmenopausal hormone therapy and selective estrogen receptor modulators on kidney outcomes in women: a protocol for systematic review and meta-analysis

BACKGROUND

The prevalence of menopause in women with or at risk of chronic kidney disease is increasing globally. Although international guidelines on menopause recommend the use of postmenopausal hormone therapy with or without selective estrogen receptor modulators for control of vasomotor symptoms, the effects of these treatments on kidney function and albuminuria are unclear. Furthermore, women with chronic kidney disease are at significantly increased risk of venous thromboembolism and malignancy, well-documented adverse effects of postmenopausal hormone therapy. Our study aims to establish the effect of these treatments on kidney function and albuminuria in women, as well as determine the safety of these treatments in the chronic kidney disease population.

METHODS

We will conduct a systematic review and meta-analysis addressing the effect and safety of postmenopausal hormone therapy and selective estrogen receptor modulators on kidney outcomes in women. We plan to search for published (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), tables of contents of relevant journals) and unpublished (ongoing studies, conference proceedings) studies in all languages examining the effect of postmenopausal hormone therapy, including selective estrogen receptor modulators, on kidney function and albuminuria, as well as the risk of adverse outcomes of these treatments in women with chronic kidney disease. Two independent investigators will screen identified abstracts and select studies that examine the effect of postmenopausal hormone therapy and selective estrogen receptor modulators on kidney outcomes in the general population or adverse outcomes in the chronic kidney disease population. Data on study population, intervention, outcomes, as well as study quality and risk of bias will be independently extracted from each eligible study. Along with descriptive presentation of data, outcome measures will be presented as meta-analyses using a random effects model. Planned subgroup analyses will be completed, and meta-regression will be performed if significant heterogeneity is noted.

DISCUSSION

By examining the effects of postmenopausal hormone therapy and selective estrogen receptor modulators on kidney function and albuminuria, the results of this systematic review and meta-analysis will inform management of postmenopausal women in the general population. Furthermore, it will evaluate the safety, including the risks of known adverse outcomes of postmenopausal hormone therapy and selective estrogen receptor modulators, in the already vulnerable chronic kidney disease population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016050651.

Adherence to Canada's Food Guide Recommendations during Pregnancy: Nutritional Epidemiology and Public Health

Background: In Canada, pregnant women are typically referred to Canada's Food Guide (CFG), a set of national dietary recommendations designed to promote adequate nutrient intake. Pregnant women are also advised to gain weight within the Institute of Medicine guidelines, which differ by prepregnancy body mass index (BMI). However, CFG recommendations do not account for prepregnancy BMI and provide no guidance on "less healthy" (LH) foods. Objective: The aim of this study was to score women's diets according to adherence to CFG recommendations and consumption of LH foods and to examine differences between these diet scores by prepregnancy BMI. Methods: Participants enrolled in the APrON (Alberta Pregnancy Outcomes and Nutrition) prospective cohort study completed a 24-h recall in their second trimester (n = 1630). A score was created on the basis of each daily dietary CFG recommendation met, ranging from 0 to 9. The distribution of consumption (grams per day) of 8 LH food groups was given a score of 0 (none) or 1, 2, or 3 (representing the lowest, middle, or highest tertiles, respectively) and summed giving a total LH score of 0-24. Results: There were few differences in CFG recommendations met by prepregnancy BMI status, although fewer women who were overweight or obese prepregnancy met the specific recommendation to consume 7-8 servings of fruit or vegetables/d than did those who were under- or normal weight (47% and 41% compared with 50% and 54%, respectively). Although differences were small, women who were obese prepregnancy had lower CFG scores (β = -0.28; 95% CI:-0.53, -0.02) and higher LH scores (β = 0.45; 95% CI: 0.04, 0.86) than did those who were normal weight. Conclusion: The study results suggest that more attention may need to be paid to individualized counseling on dietary recommendations that take account of prepregnancy BMI.

Women's Heart Health: Knowledge, Beliefs, and Practices of Canadian Physicians

BACKGROUND

Heart disease is a leading cause of morbidity and mortality in women. To date, the majority of knowledge regarding heart disease is based on research conducted in men. As a result, a male-oriented model of heart disease constitutes the basis for diagnostic and therapeutic strategies for both sexes. This article reports findings from the first survey of Canadian physicians to examine their knowledge, beliefs, and practices regarding heart disease in women.

MATERIALS AND METHODS

This cross-sectional survey, adapted from an instrument used in the United States, was undertaken in the spring of 2015. A sample of 504 physicians from a randomly selected sample of online responses was produced.

RESULTS

Overall, physician responses demonstrate a general lack of awareness regarding the prevalence and approaches to the identification of, and treatments for, heart disease in women. In addition, physicians did not provide high ratings of their own effectiveness in supporting female patients to prevent or manage heart disease. The barriers that physicians face and the strategies to support them in improving women's heart health were explored.

CONCLUSIONS

There is a clear need to educate physicians about heart disease in women and its prevention and management. More female-specific research, prevention, and clinical programs will enhance our ability to significantly improve cardiovascular health in Canadian women.

Hypertension Canada's 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension. This year, we introduce 10 new guidelines. Three previous guidelines have been revised and 5 have been removed. Previous age and frailty distinctions have been removed as considerations for when to initiate antihypertensive therapy. In the presence of macrovascular target organ damage, or in those with independent cardiovascular risk factors, antihypertensive therapy should be considered for all individuals with elevated average systolic nonautomated office blood pressure (non-AOBP) readings ≥ 140 mm Hg. For individuals with diastolic hypertension (with or without systolic hypertension), fixed-dose single-pill combinations are now recommended as an initial treatment option. Preference is given to pills containing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in combination with either a calcium channel blocker or diuretic. Whenever a diuretic is selected as monotherapy, longer-acting agents are preferred. In patients with established ischemic heart disease, caution should be exercised in lowering diastolic non-AOBP to ≤ 60 mm Hg, especially in the presence of left ventricular hypertrophy. After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBP lowering to < 140 mm Hg is not recommended. Finally, guidance is now provided for screening, initial diagnosis, assessment, and treatment of renovascular hypertension arising from fibromuscular dysplasia. The specific evidence and rationale underlying each of these guidelines are discussed.

Development and Preliminary Validation of a Comprehensive Questionnaire to Assess Women's Knowledge and Perception of the Current Weight Gain Guidelines during Pregnancy

The aim of this study was to develop and validate an electronic questionnaire, the Electronic Maternal Health Survey (EMat Health Survey), related to women's knowledge and perceptions of the current gestational weight gain guidelines (GWG), as well as pregnancy-related health behaviours. Constructs addressed within the questionnaire include self-efficacy, locus of control, perceived barriers, and facilitators of physical activity and diet, outcome expectations, social environment and health practices. Content validity was examined using an expert panel (n = 7) and pilot testing items in a small sample (n = 5) of pregnant women and recent mothers (target population). Test re-test reliability was assessed among a sample (n = 71) of the target population. Reliability scores were calculated for all constructs (r and intra-class correlation coefficients (ICC)), those with a score of >0.5 were considered acceptable. The content validity of the questionnaire reflects the degree to which all relevant components of excessive GWG risk in women are included. Strong test-retest reliability was found in the current study, indicating that responses to the questionnaire were reliable in this population. The EMat Health Survey adds to the growing body of literature on maternal health and gestational weight gain by providing the first comprehensive questionnaire that can be self-administered and remotely accessed. The questionnaire can be completed in 15-25 min and collects useful data on various social determinants of health and GWG as well as associated health behaviours. This online tool may assist researchers by providing them with a platform to collect useful information in developing and tailoring interventions to better support women in achieving recommended weight gain targets in pregnancy.

Hypertension Canada's 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension

Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force provides annually updated, evidence-based recommendations to guide the diagnosis, assessment, prevention, and treatment of hypertension. This year, we present 4 new recommendations, as well as revisions to 2 previous recommendations. In the diagnosis and assessment of hypertension, automated office blood pressure, taken without patient-health provider interaction, is now recommended as the preferred method of measuring in-office blood pressure. Also, although a serum lipid panel remains part of the routine laboratory testing for patients with hypertension, fasting and nonfasting collections are now considered acceptable. For individuals with secondary hypertension arising from primary hyperaldosteronism, adrenal vein sampling is recommended for those who are candidates for potential adrenalectomy. With respect to the treatment of hypertension, a new recommendation that has been added is for increasing dietary potassium to reduce blood pressure in those who are not at high risk for hyperkalemia. Furthermore, in selected high-risk patients, intensive blood pressure reduction to a target systolic blood pressure ≤ 120 mm Hg should be considered to decrease the risk of cardiovascular events. Finally, in hypertensive individuals with uncomplicated, stable angina pectoris, either a β-blocker or calcium channel blocker may be considered for initial therapy. The specific evidence and rationale underlying each of these recommendations are discussed. Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force will continue to provide annual updates.

Obesity Prevention from Conception: A Workshop to Guide the Development of a Pan-Canadian Trial Targeting the Gestational Period

This report summarizes a meeting, Obesity Prevention from Conception, held in Ottawa in 2012. This planning workshop was funded by the Canadian Institutes of Health Research (CIHR) to bring together researchers with expertise in the area of maternal obesity (OB) and weight gain in pregnancy and pregnancy-related disease to attend a one-day workshop and symposium to discuss the development of a cross-Canada lifestyle intervention trial for targeting pregnant women. This future intervention will aim to reduce downstream OB in children through encouraging appropriate weight gain during the mother’s pregnancy. The workshop served to (i) inform the development of a lifestyle intervention for women with a high pre-pregnancy body mass index (BMI), (ii) identify site investigators across Canada, and (iii) guide the development of a grant proposal focusing on the health of mom and baby. A brief summary of the presentations as well as the focus groups is presented for use in planning future research.