Andrea Lausman

Obstetric outcomes of women with intracranial neoplasms

To determine the obstetric outcomes of women diagnosed with a primary intracranial neoplasm prior to or during pregnancy and the puerperium.

A rare etiology of delayed postpartum hemorrhage.

BACKGROUNDnPostpartum hemorrhage, immediate or delayed, is a leading cause of maternal death. The most common etiologies are retained products of conception, infection, and subinvolution of the placental implantation site.nnnCASEnA 31-year-old woman, gravida 1, para 0, had an uneventful pregnancy after infertility treatment. She was delivered by intrapartum Caesarean section because of arrest of descent. Twelve days after delivery she had profuse, intermittent vaginal bleeding, but physical examination and pelvic ultrasound failed to reveal the cause. Angiography was performed and showed a left uterine artery pseudoaneurysm that was successfully treated with arterial embolization.nnnCONCLUSIONnUse of uterine angiography and embolization at an early stage in the search for the etiology of postpartum hemorrhage helps to decrease morbidity and mortality.

Intrahepatic Cholestasis of Pregnancy in Women With a Multiple Pregnancy: An Analysis of Risks and Pregnancy Outcomes

OBJECTIVEnThis study was conducted to assess the incidence and perinatal outcomes of multiple pregnancies complicated by intrahepatic cholestasis of pregnancy in an urban population.nnnMETHODSnWe performed a retrospective chart review of all multiple gestation deliveries at our institution between January 2004 and December 2005. Antepartum and delivery data were collected for all patients. Symptoms and treatment were also abstracted for patients in whom intrahepatic cholestasis was diagnosed. We used the Student two-tail t test and Fisher exact test to examine the differences between multiple gestation pregnancies with and without cholestasis of pregnancy.nnnRESULTSnData were available for 263 multiple pregnancies. The incidence of cholestasis was 4.2% (11/263), with a mean onset at 29.4 weeks. There were no differences in mean gestational age at delivery, preterm delivery rate, meconium histiocytosis, incidence of preeclampsia, or incidence of postpartum hemorrhage between women with and those without cholestasis. There were no intrauterine fetal deaths in the cholestasis group.nnnCONCLUSIONnWomen with multiple gestations complicated by cholestasis of pregnancy do not have increased adverse perinatal outcomes. The absence of unexplained fetal demise may be a result of routine delivery before 40 weeks gestation in multiple pregnancies.

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.

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 wasnt pregnant and (b) decisions that would be made if the patient hadnt 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.

Episiotomy Technique and Management of Anal Sphincter Tears—A Survey of Clinical Practice and Education

OBJECTIVEnTo ascertain current techniques of episiotomy used by obstetrics and gynaecology faculty members and residents in an academic department and to determine the current management strategies for third and fourth degree tears.nnnMETHODnA 14-question anonymous online survey was circulated to all faculty members and residents in the University of Toronto Department of Obstetrics and Gynaecology between October 2015 and March 2016. Results were analyzed descriptively or with Fisher exact test.nnnRESULTSnThe survey response rate was 65.5% (169/258) among 108 faculty members and 61 residents. A history of clinical teaching regarding episiotomy was reported by 87% of faculty members and 75.4% of residents. Right mediolateral episiotomy was the most frequently used method among faculty members (88.0%) and residents (95.1%). The majority of respondents indicated that they would use an end-to-end technique for repair in the labour and delivery room under regional anaesthesia. Prophylactic antibiotics were never prescribed by 18.5% of faculty members and 13.1% of residents for third or fourth degree tears. In analysis by type of training, respondents who had taken a workshop or formal class were significantly more likely to prescribe physiotherapy postpartum (Pxa0= 0.001).nnnCONCLUSIONnThe most common reported method of learning episiotomy was clinical experience. A substantial number of responses differed from current SOGC guidelines for episiotomy technique and repair and management of anal sphincter injury. We propose developing a workshop and/or simulation-based method of instruction for episiotomy technique and repair.