Darine El-Chaar

Risk of birth defects increased in pregnancies conceived by assisted human reproduction

OBJECTIVE To assess the risk of birth defects in infants born after assisted human reproduction (AHR). DESIGN Retrospective cohort study. SETTING Niday Perinatal Database for the province of Ontario, 82 sites, both primary and tertiary centers. PATIENT(S) In 2005, information about reproductive assistance was reported for 61,569 deliveries. INTERVENTION(S) The prevalence of birth defects diagnosed in the prenatal period or at birth was estimated for all types of AHR together and then by type of procedure. MAIN OUTCOME MEASURE(S) The excess risks of birth defects by AHR were calculated by unconditional logistic regressions using spontaneously conceived pregnancies as the reference and were expressed by odds ratio and 95% confidence intervals and adjusted for maternal age, smoking, infant gender, gestation, and parity. RESULT(S) The prevalence of birth defects with AHR procedures was 2.91%, which was 1.55-fold higher (95% confidence interval [CI], 1.03-2.38) than in the non-AHR population (1.86%). Specific anomalies that increased with AHR were gastrointestinal (odds ratio [OR], 9.85; 95% CI, 3.44-28.44), cardiovascular (OR, 2.30; 95% CI, 1.11-4.77), and musculoskeletal defects (OR, 1.54; 95% CI, 0.48-4.94). The risks of birth defects by types of AHR were 2.35% for ovulation induction, 2.89% for IUI, and 3.45% for IVF. CONCLUSION(S) There is a significant increased risk of birth defects associated with AHR, and the risk is higher in IVF and IUI. The potential risk of anomalies associated with AHR may be considered in the counseling that is offered to infertile couples.

The effect of maternal Class III obesity on neonatal outcomes: a retrospective matched cohort study

Objectives: To compare outcomes of neonates born from women with Class III obesity with those whose mothers were of normal body weight. Methods: A retrospective cohort study of live-born singleton infants was undertaken. Maternal prepregnancy body mass index (BMI) defined matched normal and Class III obese cohorts. Multivariable regression models were used to determine adjusted relative odds ratios (aOR) and 95% confidence intervals (CI) for selected adverse neonatal outcomes. Results: Newborns exposed to maternal Class III obesity had greater risks of fetal overgrowth and low cord artery pH. Class III obesity was protective against small for gestational age and low birthweight. There was no difference in the risk of preterm delivery, meconium in the amniotic fluid or breastfeeding initiation. Conclusions: The new knowledge generated by this study provides further information on unique challenges faced by newborns of women with Class III obesity, suggesting more specialized care in the intrapartum and neonatal periods may be beneficial.

Does Cervical Ripening at Term Using a High Volume Foley Catheter Result in a Lower Caesarean Section Rate Than a Low Volume Foley Catheter? A Systematic Review and Meta-Analysis

Cervical ripening with a Foley catheter before induction of labour is a common obstetrical intervention. In this study we aimed to evaluate primarily the relationship between high or low volume Foley catheters used for cervical ripening and Caesarean section, and secondarily the relationship between Foley catheter volume, cervical ripeness, and time to delivery. We searched Medline and Embase from their inceptions with the assistance of an experienced librarian. All abstracts and complete articles were independently reviewed by two reviewers, according to predefined inclusion criteria. Six hundred forty-eight abstracts were identified, and 30 complete articles were read in full. Three articles with a total of 575 participating women met the inclusion criteria. The rate of Caesarean section with use of 80 mL Foley catheters was not significantly different from the rate using 30 mL Foley catheters (RR 0.82; 95% CI 0.48 to 1.41). A favourable cervix (which was defined heterogeneously) was more common with high volume catheters (RR 1.72; 95% CI 1.46 to 2.04), and failure to deliver in 24 hours was lower (RR 0.70; 95% CI 0.54 to 0.90). High volume Foley catheters improve the likelihood of a favourable cervix and chance of delivery in 24 hours more than low volume Foley catheters. As a more favourable cervix before induction of labour is associated with a lower rate of Caesarean section, a randomized controlled trial comparing high and low volume Foley catheters for cervical ripening using Caesarean section as the primary outcome is warranted.

Simulation-Based Education in Obstetrics and Gynaecology Training in Canada

Simulation is no longer the way of the future; it is the way of the now. As such, simulation-based education is becoming increasingly prevalent in medical and surgical training.1–4 Residents and residency program directors alike place value on simulation training and see a growing role for it in their respective learning and educating.5 The emphasis on the development of medical skills outside the operating room and away from the patient’s bedside has been motivated by various forces. Firstly, a steady reduction in resident duty hours has taken place in the past decade, and an overhaul of the 24-hour call shift is looming in Canada. Secondly, a decrease in operating time, which demands increased surgical efficiency, is a further stress on the operating room as a learning environment.6 Next, concerns regarding patient safety, in an increasingly litigious climate, have done away with the now archaic paradigm of “see one, do one, teach one.”7 This climate of increased patient safety has also led to a need for increased resident education in the intrinsic CanMEDS roles, as teamwork, leadership, health advocacy, professionalism, and communication skills are recognized as valuable skills. Lastly, as teaching centres care for increasingly complex patients, fewer routine cases become available for learners.6

Comparison of outcomes between induction of labor and spontaneous labor for term breech – A systemic review and meta analysis

OBJECTIVES Few studies have assessed the impact of induction of labor on breech presentation. This study aims to summarize the effect of induction of labor of breech presentation on perinatal morbidity. METHODS Literature review was done in Medline, Embase, Web of science and Cochrane Library up to 20 October 2017. Randomized control studies, cohort studies, and case control publishing studies comparing induction of labor versus spontaneous labor of singleton live breech birth were included. Perinatal morbidity was calculated by RevMan 5 and presented by pooled odds ratio with 95% confidence intervals. RESULTS Cesarean section rate and neonatal intensive care unit admission were increased in induction of breech labor as compared with spontaneous breech labor. No significant difference in umbilical cord blood base excess ≤ -12 mmol/L, Apgar 5 min < 7, Apgar 5 min < 4, umbilical cord blood PH < 7, neonatology unit admission, maternal fever, and intrapartum stillbirth between the two groups was found. CONCLUSIONS Induction of breech labor has higher cesarean section rate and NICU perinatal morbidity compared to spontaneous breech labor. The neonatal outcomes were otherwise similar across both groups. Eligibility for induction of breech labor needs to be assessed carefully according to individual situation.

Case series of multiple repeat caesarean sections: operative, maternal, and neonatal outcome

Abstract Objective: The objective of this study is to review the maternal and neonatal morbidity and mortality associated with six or more caesarean section (CS). Methods: We conducted a retrospective chart review, at King Abdulaziz University Hospital (KAUH) in Jeddah, for all patients admitted between 2000 through 2010 and identified five patients having more than six CS deliveries. Results: Deliveries occurred in the ranges of 31–38 weeks, from which four cases required emergency CS. There were two cases in the series with a placenta previa. There was a single case of uterine dehiscence. Only one case required a blood transfusion and was complicated with a placenta accreta, bladder injury, urinary tract infection, and prolonged maternal hospital stay with neonatal intensive care unit (NICU) admission. All cases had moderate to severe adhesion intra-operatively. Operative time was long in all cases with a range 55–106 min. One of the five cases had a postoperative wound infection. Finally, none of the current series showed fetal or maternal mortalities. Conclusions: The long-term complications associated with CS should be discussed with patients in the first and subsequent pregnancies. This case series highlighted the outcomes in these unique cases of higher order caesareans.

Fetal segmental spinal dysgenesis and unusual segmental agenesis of the anterior spinal artery

Segmental spinal dysgenesis (SSD) is a rare congenital spinal abnormality characterized by segmental dysgenesis or agenesis of the thoracolumbar or lumbar spine, congenital kyphosis, and abnormal configuration of the underlying spinal cord. A unique feature of SSD is that the vertebrae are present above and below the defect, and there is often a lower cord segment in the caudal spinal canal. We report a fetal MRI case of SSD with postmortem and neuropathological correlations. Our report confirms already published findings including the presence of a neurenteric cyst but is the first to document anterior spinal artery segmental agenesis in SSD.

Impact of relaxation of the one‐child policy on maternal mortality in Guangzhou, China

To assess the impact of the one‐child policy in China on maternal mortality.

Necrotizing Myositis: A Severe Tension-Free Vaginal Tape-Obturator Surgical Site Infection

Surgical removal of tension-free vaginal tape-obturator mesh, with irrigation and debridement of the left adductor compartment, was completed by a urogynaecologist with the assistance of an orthopedic surgeon (Figure 2). Wound cultures demonstrated Streptococcus constellatus and mixed anaerobic flora. Symptoms resolved completely after 4 weeks of intravenous ceftriaxone and metronidazole administration, followed by 3 weeks of oral amoxicillin-clavulanate.

Rapamycin-Sensitive Signal Transduction Pathways and the Control of Adipogenesis

Adipose tissue development occurs in early life, followed by ongoing adipose tissue remodelling in the adult. Formation of new adipocytes (adipogenesis) occurs via the differ-entiation of committed progenitor cells, known as preadipocytes. In positive energy balance, existing adipocytes enlarge to a finite degree to store excess calories; adipogenesis then ensues to enlarge the reservoir capacity.