Donna Jones

Obesity in Pregnancy

OBJECTIVE To review the evidence and provide recommendations for the counselling and management of obese parturients. OUTCOMES Outcomes evaluated include the impact of maternal obesity on the provision of antenatal and intrapartum care, maternal morbidity and mortality, and perinatal morbidity and mortality. EVIDENCE Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to April 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The evidence obtained was reviewed and evaluated by the Maternal Fetal Medicine and Clinical Practice Obstetric Committees of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in this guideline should increase recognition of the issues clinicians need to be aware of when managing obese women in pregnancy, improve communication and consultation amongst the obstetrical care team, and encourage federal and provincial agencies to educate Canadians about the values of entering pregnancy with as healthy a weight as possible. RECOMMENDATIONS 1. Periodic health examinations and other appointments for gynaecologic care prior to pregnancy offer ideal opportunities to raise the issue of weight loss before conception. Women should be encouraged to enter pregnancy with a BMI < 30 kg/m(2), and ideally < 25 kg/m(2). (III-B). 2. BMI should be calculated from pre-pregnancy height and weight. Those with a pre-pregnancy BMI > 30 kg/m(2) are considered obese. This information can be helpful in counselling women about pregnancy risks associated with obesity. (II-2B). 3. Obese pregnant women should receive counselling about weight gain, nutrition, and food choices. (II-2B). 4. Obese women should be advised that they are at risk for medical complications such as cardiac disease, pulmonary disease, gestational hypertension, gestational diabetes, and obstructive sleep apnea. Regular exercise during pregnancy may help to reduce some of these risks. (II-2B). 5. Obese women should be advised that their fetus is at an increased risk of congenital abnormalities, and appropriate screening should be done. (II-2B). 6. Obstetric care providers should take BMI into consideration when arranging for fetal anatomic assessment in the second trimester. Anatomic assessment at 20 to 22 weeks may be a better choice for the obese pregnant patient. (II-2B). 7. Obese pregnant women have an increased risk of Caesarean section, and the success of vaginal birth after Caesarean section is decreased. (II-2B). 8. Antenatal consultation with an anaesthesiologist should be considered to review analgesic options and to ensure a plan is in place should a regional anaesthetic be chosen. (III-B). 9. The risk of venous thromboembolism for each obese woman should be evaluated. In some clinical situations, consideration for thromboprophylaxis should be individualized. (III-B).

Active management of the third stage of labour: Prevention and treatment of postpartum hemorrhage

To review the clinical aspects of postpartum hemorrhage (PPH) and provide guidelines to assist clinicians in the prevention and management of PPH. These guidelines are an update from the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical practice guideline on PPH, published in April 2000.

The predictive value of 18 and 22 week uterine artery Doppler in patients with low first trimester maternal serum PAPP-A †

To determine if the addition of uterine artery (UA) Doppler pulsatility index (PI) at 18 and 22 weeks of gestation improves the predictive accuracy of low first trimester pregnancy associated plasma protein A (PAPP‐A) in the detection of adverse obstetrical outcomes.

SOGC CLINICAL PRACTICE GUIDELINESActive management of the third stage of labour: Prevention and treatment of postpartum hemorrhage: No. 235 October 2009 (Replaces No. 88, April 2000)☆

To review the clinical aspects of postpartum hemorrhage (PPH) and provide guidelines to assist clinicians in the prevention and management of PPH. These guidelines are an update from the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical practice guideline on PPH, published in April 2000.

OC31: Women's satisfaction with the OSCAR (One‐Stop Clinic Assessment of Risk) model of first‐trimester combined screening

Objectives: This study evaluated women’s satisfaction with the OSCAR (One-Stop Clinic Assessment of Risk) first-trimester combined screening (FTS) model introduced in Calgary, Canada in March 2006. Methods: The FTS OSCAR model provides pretest counseling, phlebotomy, blood assay for fβ-hCG, PAPP-A (Delfia TM Xpress), nuchal translucency (NT) scan, the FTS risk calculation (Astraia) and post-test counseling during a 90-min appointment. A satisfaction survey was developed to measure expectations and satisfaction with these various components of service. Additional information collected included the women’s demographics, their recall of their screen result (positive or negative) and whether they felt reassured with testing. Between 13 March 2006–2007, all women referred for the 11–13 + 6 week FTS who agreed to complete the survey were included. Results: Response rate was 75% (3763/5013). Overall, 98.1% of the women were either very satisfied or satisfied and 95.6% felt their expectations were met. These results were independent of maternal age, parity and education. Most women were reassured by testing regardless of results (99.3% and 82.1% of the screen-negative and screen-positive (≥1/300 women, respectively). Most (93%) stated that screening early in pregnancy and receiving test results at the same visit (95.6%) was very important. Conclusions: The FTS OSCAR model meets women’s expectations and is associated with a high degree of satisfaction in terms of timing of screening and rapid availability of results. A high proportion of women were reassured by their results regardless of whether they were screen negative or positive. There was also a relatively low uptake of prenatal diagnosis among the screen-positive women (49%). This may imply that women favor the personal risk assessment and benefit from the 1-1 post-counseling of the OSCAR model. Further research is under way to address these questions.