Colleen M. O’Connell

Maternal and Perinatal Outcomes of Eclampsia: Nova Scotia, 1981-2000

OBJECTIVE To determine the prevalence of eclampsia and the associated maternal and perinatal outcomes in the province of Nova Scotia. METHODS From the Nova Scotia Atlee Perinatal Database, the population-based rates of preeclampsia, eclampsia, and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome for the period 1988 to 2000 were determined. A retrospective case review was then performed of all women with eclampsia at the tertiary maternity hospital in Halifax, Nova Scotia, Womens Hospital, IWK Health Centre, for the years 1981 to 2000. RESULTS In the province of Nova Scotia from 1988 to 2000, there were 142,362 births. Thirty-nine women developed eclampsia (0.27/1000). Over this time interval, the prevalence of severe preeclampsia fell from 2.08% to 1.63%, and the diagnosis of HELLP syndrome increased from 0.03% to 0.31%. At the Womens Hospital, IWK Health Centre, between 1981 and 2000, there were 31 cases of eclampsia in 105,651 deliveries (0.29/1000). Sixty-one percent of first convulsions occurred antepartum, 13% occurred intrapartum, and 26% occurred postpartum. Eighty-one percent of women reported prodromal symptoms. Sixty-one percent of the women received anti-hypertensive therapies, 48% received antiepileptic therapies, and 97% received magnesium sulfate. Ten percent of the women had convulsions while on magnesium sulfate therapy. Antepartum eclampsia was associated with increased rates of general anaesthesia (26%) and Caesarean section (79%). There were no maternal deaths, but the rate of major maternal complications was 32%. The perinatal mortality rate was 64 in 1000 deliveries, and the rate of severe perinatal complications was 56%. CONCLUSION The incidence of eclampsia in Nova Scotia is 0.27 per 1000 deliveries. Although rare, this condition is associated with significant maternal and perinatal morbidity.

Acute Disseminated Intravascular Coagulation in Obstetrics: A Tertiary Centre Population Review (1980 to 2009)

OBJECTIVE To determine the antecedent factors, morbidity, and mortality associated with disseminated intravascular coagulation (DIC) in a Nova Scotia tertiary maternity hospital over a 30-year period. METHODS Cases of DIC were identified from the Nova Scotia Atlee Perinatal Database for the years 1980 to 2009 and the hospital charts reviewed. The clinical diagnosis of DIC was confirmed or refuted using a combination of the International Society of Thrombosis and Haemostasis scoring system and an obstetrical DIC-severity staging system. The cause of DIC was determined from chart review. Maternal outcomes included massive transfusion (≥ 5 units), hysterectomy, admission to ICU, acute tubular necrosis (ATN) requiring dialysis, and death. Neonatal outcomes included Apgar scores, birth weight, NICU admission, and death. Treatment of DIC was assessed by blood products administered, postpartum hemorrhage management, and laboratory measurements. RESULTS There were 49 cases of DIC in 151 678 deliveries (3 per 10,000) over the 30 years. Antecedent causes included placental abruption (37%), postpartum hemorrhage or hypovolemia (29%), preeclampsia/HELLP (14%), acute fatty liver (8%), sepsis (6%), and amniotic fluid embolism (6%). The associated maternal morbidity included transfusion ≥ 5 units (59%), hysterectomy (18%), ICU admission (41%), and ATN requiring dialysis (6%). There were three maternal deaths, giving a case fatality rate of 1 in 16. The perinatal outcomes included stillbirth (25%), neonatal death (5%), and NICU admission (72.5%). CONCLUSION Obstetrical DIC is an uncommon condition associated with high maternal and perinatal morbidity and mortality. Prompt recognition and treatment with timely administration of blood products is crucial in the management of this life-threatening disorder.

Maternal Critical Care in Obstetrics

OBJECTIVE To determine the factors leading to maternal critical care in a tertiary obstetric hospital and the associated trends. METHODS We conducted a review of the medical records of all women who required transfer for critical care from a free-standing obstetric unit to a general hospital over a 24-year period (1982-2005). RESULTS During the 24-year period there were five maternal deaths directly associated with 122,001 deliveries (4.1/100,000) and, in addition, 117 women were transferred to the general hospital for critical care (1.0/1000). The death-to-transfer ratio was 1 in 23. Of the women transferred, 93/117 (79.5%) required intensive care and 24/117 (20.5%) needed specialized medical or surgical services not available in the obstetric unit. Of the women transferred, 16/117 (13.7%) were antepartum, and 101/117 (86.3%) were postpartum. Hemorrhage and hypertensive disorders combined to make up 56.4% of all maternal transfers. Women with a multiple pregnancy were more likely to require transfer than those with a singleton pregnancy (RR 3.34; 95% CI 1.4-7.59, P=0.01). CONCLUSION The majority of maternal transfers for critical care occur postpartum, and in more than half of the cases the reason for transfer is hemorrhage or hypertensive disease. Women with a multiple pregnancy had a significantly greater rate of transfer than those with a singleton, and women with a triplet pregnancy had a greater rate than those with twins. There was a non-significant increase in the number of maternal transfers over the study period.

Maternal and Neonatal Outcomes in Pregnancies Complicated by Systemic Lupus Erythematosus: A Population-Based Study

OBJECTIVE To determine maternal and neonatal outcomes in pregnancies complicated by systemic lupus erythematosus (SLE). METHODS In a retrospective cohort study using the Nova Scotia Atlee Perinatal Database, 97 pregnancies in women with SLE, with 99 live births, were compared with 211 355 pregnancies in women without SLE and their 214 115 babies. All were delivered in Nova Scotia between 1988 and 2008. RESULTS In women with SLE, gestational age at birth and mean neonatal birth weight were lower (P < 0.001) than in women without SLE. On bivariate analysis, severe preeclampsia, Caesarean section, newborn resuscitation for > 3 minutes, respiratory distress syndrome, assisted ventilation, bronchopulmonary dysplasia, patent ductus arteriosus, mild to moderate intraventricular hemorrhage, retinopathy of prematurity, and congenital heart block in neonates were significantly more frequent in the women with SLE. Logistic regression analysis identified that having SLE increased the risks of Caesarean section (OR 1.8; 95% CI 1.1 to 2.8, P = 0.005), postpartum hemorrhage (OR 2.4; 95% CI 1.3 to 4.3, P = 0.003), need for blood transfusion (OR 6.9; 95% CI 2.7 to 17, P = 0.001), postpartum fever (OR 3.2; 95% CI 1.7 to 6.1, P = 0.032), small for gestational age babies (OR 1.7; 95% CI 1.005 to 2.9, P = 0.047), and gestational age ≤ 37 weeks (OR 2.1; 95% CI 1.3 to 3.4, P = 0.001). Neonatal death was not shown to be more common in women with SLE (RR 3.05; CI 0.43 to 21.44, P = 0.28). CONCLUSION Mothers with SLE have an increased risk of Caesarean section, postpartum hemorrhage, and blood transfusion. They are more likely to deliver premature babies, smaller babies, and babies with congenital heart block.

Contribution of Select Maternal Groups to Temporal Trends in Rates of Caesarean Section

OBJECTIVE To estimate the contribution of select maternal groups to temporal trends in Caesarean section (CS) rates. METHODS Using the Nova Scotia Atlee Perinatal Database, all deliveries by CS during the 24-year period from 1984 to 2007, at the Womens Hospital, IWK Health Centre were identified. Deliveries by CS were classified into groups using parity (nullipara/multipara), plurality (singleton/multiple), presentation (cephalic/breech/transverse), gestational age (term/preterm), history of previous CS (previous CS/no previous CS), and labour (spontaneous/induced/no labour). CS rates in each group and the contribution of each group to the overall CS rate was determined for three eight-year epochs. The risk of CS in each group over time, accounting for identified maternal, fetal, and obstetric practice factors, was evaluated using logistic regression. RESULTS Of 113,016 deliveries, 23,232 (20.6%) were identified as deliveries by CS meeting the inclusion and exclusion criteria. The CS rate rose from 16.8% in 1984 to 1991 to 26.8% in 2000 to 2007 (P < 0.001). The biggest contributors to the overall CS rate in the last study epoch (2000-2007) were nulliparous women with singleton, cephalic, term pregnancies with spontaneous or induced labour; women with singleton, cephalic, term pregnancies with previous CS; and women with breech presentation. Adjusted analyses explained some increases in the rate of CS and demonstrated reduced risks in others. CONCLUSION Only some temporally increased CS rates in select maternal groups remain increased after adjusting for confounding variables. The identification of potentially modifiable maternal risk factors, re-evaluation of the indications and techniques for induction of labour in nulliparous women, provision of clinical services for vaginal birth after Caesarean section, and external cephalic version for selected breech presentation are important clinical management areas to consider for safely lowering the Caesarean section rate.

The Influence of Hospital Closures in Nova Scotia on Perinatal Outcomes

OBJECTIVE To evaluate the effect of hospital closures on critical obstetrical interventions and perinatal outcomes in rural communities in Nova Scotia, Canada. METHODS A population-based cohort study was carried out for the years 1988 to 2002, using data extracted from the Nova Scotia Atlee Perinatal Database. Regions of maternal residence were defined geographically and administratively as Eastern, Northern,Western, and Central. The time periods of 1988 to 1993 and 1996 to 2002 were chosen based on the timing of hospital closures. Changes in rates of several perinatal outcomes were examined by region in relation to the extent of hospital closures experienced by that region. RESULTS The majority of hospital closures occurred in 1994 to 1995 with the establishment of new health regions, and affected the Western region most profoundly. In comparison with the Central region (relative risk [RR], 0.56; 95% confidence interval [CI], 0.53-0.59), the temporal reduction in the rate of forceps-assisted vaginal delivery was smaller in the Western region (RR, 0.83; 95% CI, 0.76-0.91; P < .001), but greater in the Northern (RR, 0.36; 95% CI, 0.32-0.41; P < .001) and Eastern (RR, 0.26; 95% CI, 0.23-0.30; P < .001) regions. The temporal increase in the rate of breastfeeding at discharge from hospital was smaller in the Northern region (RR, 1.36; 95% CI, 1.29-1.45; P < .001) compared to that in the Central region (RR, 1.55; 95% CI, 1.49-1.61). The decrease in the rate of fetal growth restriction was smaller in the Western (RR, 0.95; 95% CI, 0.87-1.02; P = .002) and Eastern (RR, 0.90; 95% CI, 0.82-0.98; P = .002) regions of residence compared to the Central region (RR, 0.75; 95% CI, 0.71-0.79). There were no significant regional differences in temporal patterns of preterm induction and/or preterm Caesarean delivery, or perinatal mortality. CONCLUSION Although trends over time demonstrated some regional differences in obstetrical interventions and perinatal outcomes, our retrospective evaluation did not reveal a consistent relationship between reductions in maternity services associated with hospital closures and systematic, population-level adverse perinatal consequences in Nova Scotia.

Canadian Stroke Best Practice Recommendations: Managing transitions of care following Stroke, Guidelines Update 2016.

Every year, approximately 62,000 people with stroke and transient ischemic attack are treated in Canadian hospitals. For patients, families and caregivers, this can be a difficult time of adjustment. The 2016 update of the Canadian Managing Transitions of Care following Stroke guideline is a comprehensive summary of current evidence-based and consensus-based recommendations appropriate for use by clinicians who provide care to patients following stroke across a broad range of settings. The focus of these recommendations is on support, education and skills training for patients, families and caregivers; effective discharge planning; interprofessional communication; adaptation in resuming activities of daily living; and transition to long-term care for patients who are unable to return to or remain at home. Unlike other modules contained in the Canadian Stroke Best Practice Recommendations (such as acute inpatient care), many of these recommendations are based on consensus opinion, or evidence level C, highlighting the absence of conventional evidence (i.e. randomized controlled trials) in this area of stroke care. The quality of care transitions between stages and settings may have a direct impact on patient and family outcomes such as coping, readmissions and functional recovery. While many qualitative and non-controlled studies were reviewed, this gap in evidence combined with the fact that mortality from stoke is decreasing and more people are living with the effects of stroke, underscores the need to channel a portion of available research funds to recovery and adaptation following the acute phase of stroke.

Women's ability to assess their urinary incontinence type using the QUID as an educational tool

Introduction and hypothesisLittle evidence is available concerning the ability of women with urinary incontinence (UI) to properly assess their problem. This study compared women’s assessments of their UI type with physicians’ diagnoses.MethodsWomen referred to a urogynecology clinic for UI were asked to anonymously answer a short validated Questionnaire for Urinary Incontinence Diagnosis (QUID) before their physician visit. Women completed the QUID and read a brief explanation of its interpretation, after which they were asked to choose their UI type: stress, urge, or mixed. Physicians, blinded to patients’ answers, conducted routine examinations and indicated their diagnoses of incontinence types. Sample size was representative of typical clinic volumes. Levels of agreement among physician diagnoses, QUID scores, and patient self-assessments of UI type were calculated with kappa (κ) statistics. Physician diagnosis was the gold standard.ResultsWe had 497 patients return the questionnaire; 338 met inclusion criteria. Mean age was 53 (±13) years. Levels of agreement among physician diagnoses and patients’ assessments of UI type (κ = 0.411, p < 0.01) and QUID scores (κ = 0.378, p < 0.01) were significant. Significant level of agreement was found among QUID scores and patients’ assessments of UI type (κ = 0.497, p < 0.001).ConclusionsWith aid of a brief standardized questionnaire, women can accurately assess their UI type. This suggests women could be educated about UI via good-quality Internet health sites and choose appropriate conservative management options.

Neonatal Outcome Following Failed Kiwi OmniCup Vacuum Extraction

OBJECTIVE To evaluate neonatal outcomes following failed vacuum extraction using the Kiwi OmniCup vacuum device. METHODS We conducted a retrospective study of 288 failed vacuum deliveries using the OmniCup device. The neonatal morbidity was recorded for each delivery. RESULTS Of the 288 women involved, 82.3% were nulliparous. In 245 cases (85.1%), failed vacuum was followed by successful forceps delivery; failed vacuum and failed forceps was followed by Caesarean section in 5.9%; failed vacuum was followed by spontaneous vaginal delivery in 3.8%; and failed vacuum was followed by Caesarean section in 5.2%. Cephalhematoma was diagnosed in 19.8% of the 288 infants delivered. There were no cases of neonatal intracranial or subgaleal hemorrhage. CONCLUSION Although the method of delivery following failed vacuum extraction is controversial, and most national guidelines warn of increased neonatal morbidity with subsequent use of forceps, the low morbidity in this study is reassuring. In our cohort, low forceps delivery (station > 2 cm) following failed vacuum extraction was not associated with serious neonatal morbidity.

A Delphi-based Consensus Statement on the Management of Anticoagulated Patients with Botulinum Toxin for Limb Spasticity

OBJECTIVE To create a consensus statement on the considerations for treatment of anticoagulated patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity. DESIGN We used the Delphi method. SETTING A multiquestion electronic survey. PARTICIPANTS Canadian physicians (N=39) who use BoNTA injections for spasticity management in their practice. INTERVENTIONS After the survey was sent, there were e-mail discussions to facilitate an understanding of the issues underlying the responses. Consensus for each question was reached when agreement level was ≥75%. MAIN OUTCOME MEASURES Not applicable. RESULTS When injecting BoNTA in anticoagulated patients: (1) BoNTA injections should not be withheld regardless of muscles injected; (2) a 25G or smaller size needle should be used when injecting into the deep leg compartment muscles; (3) international normalized ratio (INR) level should be ≤3.5 when injecting the deep leg compartment muscles; (4) if there are clinical concerns such as history of a fluctuating INR, recent bleeding, excessive or new bruising, then an INR value on the day of injection with point-of-care testing or within the preceding 2-3 days should be taken into consideration when injecting deep compartment muscles; (5) the concern regarding bleeding when using direct oral anticoagulants (DOACs) should be the same as with warfarin (when INR is in the therapeutic range); (6) the dose and scheduling of DOACs should not be altered for the purpose of minimizing the risk of bleeding prior to BoNTA injections. CONCLUSIONS These consensus statements provide a framework for physicians to consider when injecting BoNTA for spasticity in anticoagulated patients. These consensus statements are not strict guidelines or decision-making steps, but rather an effort to generate common understanding in the absence of evidence in the literature.