Louise Duperron

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 Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice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).

Bacteriology of Amniotic Fluid in Women With Suspected Cervical Insufficiency

OBJECTIVE To determine the prevalence of mid-trimester microbial invasion of the amniotic cavity (MIAC) in women with suspected cervical insufficiency. METHODS A prospective observational cohort study was performed in women with suspected cervical insufficiency and visible fetal membranes who were undergoing amniocentesis to rule out MIAC between 16 and 26 weeks of gestation. Women with preterm premature rupture of membranes, regular uterine contractions, or who had a cervical cerclage were excluded. Gram staining of amniotic fluid, glucose and lactate dehydrogenase (LDH) levels in amniotic fluid, and aerobic and anaerobic amniotic fluid cultures were performed, along with polymerase chain reaction (PCR) for the detection of Ureaplasma and Mycoplasma species. RESULTS Fifteen women with a mean gestational age of 22.6 +/- 2.3 weeks were included in the study. The diagnosis of MIAC was confirmed in 47% (7/15), of whom 20% (3/15) were infected with more than one bacterial strain and 33% (5/15) with Ureaplasma species. According to receiver-operator curve analyses, amniotic fluid levels of glucose were associated with MIAC (P = 0.02), but not amniotic fluid LDH (P = 0.25). CONCLUSION MIAC is present in approximately one half of women with suspected cervical insufficiency and visible fetal membranes at speculum examination.

Induction of Labour

OBJECTIVE To review the most current literature in order to provide evidence-based recommendations to obstetrical care providers on induction of labour. OPTIONS Intervention in a pregnancy with induction of labour. OUTCOMES Appropriate timing and method of induction, appropriate mode of delivery, and optimal maternal and perinatal outcomes. EVIDENCE Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library in 2010 using appropriate controlled vocabulary (e.g., labour, induced, labour induction, cervical ripening) and key words (e.g., induce, induction, augmentation). Results were restricted to systematic reviews, randomized control 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 the end of 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The evidence in this document was rated using criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). SUMMARY STATEMENTS: 1. Prostaglandins E(2) (cervical and vaginal) are effective agents of cervical ripening and induction of labour for an unfavourable cervix. (I) 2. Intravaginal prostaglandins E(2) are preferred to intracervical prostaglandins E(2) because they results in more timely vaginal deliveries. (I).

Umbilical and placental vessels: Modifications of their mechanical properties in preeclampsia

OBJECTIVES Our objective in this study was to assess the basic mechanical properties of umbilical and chorionic vessels of placentas delivered after both normal and preeclamptic pregnancies. STUDY DESIGN Placentas were selected when the parturient women were admitted to the delivery room. Normal pregnancy (n = 17) was characterized by delivery at term (38 to 40 weeks) after uncomplicated pregnancy without any medication. Preeclamptic pregnancy (n = 7) was characterized by delivery after 28 weeks of pregnancy (28 to 39 weeks) after sustained hypertension and proteinuria. Arteries and veins from the umbilical cord and chorionic plate were prepared in rings for in vitro study in tissue baths. Passive and active (on stimulation by potassium chloride or serotonin) mechanical properties of these vessels were studied. RESULTS In vessels from normal pregnancy, responsiveness, but not sensitivity, was increased with increasing passive tension on vessels until optimal tension was reached. The passive stretch-tension curve was shifted downward in umbilical veins and upward in umbilical arteries and chorionic veins obtained from preeclamptic mothers in comparison with normal parturient women. In the absence of passive tension, contractions in response to potassium chloride were produced in all umbilical veins and some chorionic veins from preeclampsia but not from normal pregnancy. Developed wall tension curves in chorionic vessels from preeclampsia were shifted upward. In umbilical veins and arteries and in chorionic veins, the optimal passive tension was lower in tissues from preeclampsia than in tissues from normal pregnancy. CONCLUSION Our results indicate that both passive and active mechanical properties of umbilical vessels are modified after pregnancy complicated by preeclampsia.

Transplacental treatment of tachycardia-induced fetal heart failure with verapamil and amiodarone: a case report.

The role that the new antiarrhythmic agents, such as verapamil and amiodarone, might play in the therapeutic strategy of tachycardia-induced fetal heart failure remains to be determined.

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.

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.

Prenatal Diagnosis of Cloverleaf Skull: Watch the Hands!

Pfeiffer syndrome is an extremely rare autosomal-dominant condition whose prenatal diagnosis has only been reported 6 times, mainly on the basis of a fetal cloverleaf skull deformity. Three types have been described, each with a different prognosis. This case report stresses the need to thoroughly analyze the fetus and particularly the fetal hands in case of prenatal observation of a cloverleaf skull. The discovery of characteristic hand abnormalities allowed the early prenatal detection of type 2 Pfeiffer syndrome in our patient.

Early versus late amniotomy for labour induction: a randomized controlled trial

Objective: To evaluate the impact of early vs. late amniotomy on delivery mode in women undergoing induction of labor. Study design: 143 women admitted for induction were randomized to early amniotomy (EA, concomitant with the beginning of oxytocin infusion; n = 71) or to late amniotomy (LA, four hours after the beginning of oxytocin; n = 72). Randomization was stratified by parity. The primary outcome was the rate of cesarean. Secondary outcomes were duration of labor and intrapartum fever. Results: The cesarean rate was similar between groups (18% vs. 17% among nulliparous; and 3% vs. 0% among parous women, in EA and LA group, respectively). However, EA was associated with shorter oxytocin-to-delivery interval (12 vs. 15 h) and a non-significant decrease in intrapartum fever (3% vs. 25%) than LA in nulliparous women (p = 0.05). Conclusion: For women undergoing oxytocin induction, early amniotomy is associated with shorter labor in nulliparous women with no effect on the risk of cesarean section in both nulliparous and multiparous women.

Case-control study comparing droperidol plus diphenhydramine with conventional treatment in hyperemesis gravidarum

Background: In 1998, a protocol consisting of droperidol/diphenhydramine combination was established at Hospital Sainte-Justine to treat hyperemesis gravidarum. Objective: To compare the efficacy of the droperidol/diphenhydramine combination with other conventional treatments used before implementation of this protocol in the treatment of hyperemesis gravidarum (HG). Methods: A nonrandomized, prospective study was conducted using a historical control of 54 patients receiving conventional antiemetic treatment and 2 study groups: 67 patients treated with intravenous droperidol 1 mg/h plus diphenhydramine 25–50 mg every 6 hours and 34 patients treated with intravenous droperidol 0.5 mg/h plus diphenhydramine 50 mg every 6 hours. Study outcomes included length of hospital stay, readmission rate, intensity of nausea and vomiting according to the National Cancer Institute scoring system, maternal body weight variation, pregnancy outcomes, and adverse effects. Study Site: Sainte-Justine Hospital in Montréal, Québec, a tertiary care university teaching hospital affiliated with the University of Montréal. Study Population: Hospitalized patients diagnosed with HG. Results: The 3 groups, comparable in terms of maternal characteristics, showed no difference in terms of length of stay. The readmission rate was lower in the group that received droperidol 1 mg/h compared with the other 2 groups. Overall, droperidol use was associated with a reduction in daily nausea and vomiting scores (p < 0.001). The most common adverse effects were xerostomia, drowsiness, constipation, and hypotension. Extrapyramidal reactions were observed in 20% of the droperidol patients. Birth defects occurred in 2.4% of the control group and 7.5% of the study group (p = 0.52). Drugs could be excluded as causal agents for the majority of malformations in 5 of 7 cases. Conclusions: Droperidol/diphenhydramine is an effective alternative for treatment of refractory HG. A large, prospective, randomized study would be required to confirm the efficacy of this treatment as well as maternal and fetal safety.