Nancy Kent

Venous Thromboembolism and Antithrombotic Therapy in Pregnancy

OBJECTIVE To present an approach, based on current evidence, for the diagnosis, treatment, and thromboprophylaxis of venous thromboembolism in pregnancy and postpartum. EVIDENCE Published literature was retrieved through searches of PubMed, Medline, CINAHL, and The Cochrane Library from November 2011 to July 2013 using appropriate controlled vocabulary (e.g. pregnancy, venous thromboembolism, deep vein thrombosis, pulmonary embolism, pulmonary thrombosis) and key words (e.g., maternal morbidity, pregnancy complications, thromboprophylaxis, antithrombotic therapy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English or French. There were no date restrictions. Grey (unpublished) literature was identified through searching the websites of clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1).

Prediction of pediatric outcome after prenatal diagnosis and expectant antenatal management of congenital cystic adenomatoid malformation.

Objective: To determine whether the congenital cystic adenomatoid malformation (CCAM) volume ratio (CVR) is associated with fetal and postnatal outcome after prenatal diagnosis and antenatal expectant management in a provincial tertiary referral center that does not offer fetal surgery. Methods: Retrospective cohort of 71 consecutive cases of prenatally diagnosed CCAM meeting study criteria (1996–2004). CVR was calculated on the initial ultrasound at the referral center, and associated with hydrops (Fisher’s exact test) and a composite adverse postnatal outcome consisting of death, intubation for respiratory distress, extracorporeal membrane oxygenation, non-elective surgery for symptomatology, or respiratory infection requiring hospital admission (Mann-Whitney test). Results: A CVR >1.6 was significantly associated with hydrops (p = 0.003). In addition, the CVR was significantly associated with the composite adverse postnatal outcome (p = 0.004) at a mean age of follow-up of 41 months (range <1–117 months). For CVR and postnatal outcome, the area-under-the-curve receiver operating characteristic was 0.81 (95% CI 0.69–0.93, p = 0.006), and choosing a CVR cut-off of <0.56, the negative predictive value was 100% (95% CI 0.85–1.00). Conclusion: In a provincial referral center with antenatal expectant management of CCAM, the CVR was associated with hydrops and postnatal outcome, with a CVR <0.56 predictive of good prognosis after birth.

Competency-Based Medical Education: The Wave of the Future*

Competency-based medical education (CBME) is a new educational paradigm that will enable the medical education community to meet societal, patient, and learner needs of the 21st century. CBME offers a renewed commitment to both clinical and educational outcomes, a new focus on assessment and developmental milestones, a mechanism to promote a true continuum of medical education, and a method to promote learner-centred curricula in the context of accountability. Accountability is central to CBME, ensuring that graduating practitioners are well-rounded and competent to provide safe and effective patient care. The structure of CBME in obstetrics and gynaecology must be rooted in, and reflect, Canadian practice. Its development and implementation require an understanding of the principles that are the foundation of CBME, along with the involvement of the entire community of obstetricians and gynaecologists and other maternity care providers. We provide here an overview of the basic principles of teaching and learning and the theories underpinning CBME.

Competency-Based Medical Education: Developing a Framework for Obstetrics and Gynaecology

The development of a Canadian competency-based medical education (CBME) curriculum in obstetrics and gynaecology, slated to begin in 2017, must be rooted in, and aligned with, the principles of CanMEDS 2015 and Competence by Design. It must also reflect the unique realities of the practice of the specialty. The Dutch Society of Obstetrics and Gynaecology has been at the forefront of the movement to design and implement competency-based training for obstetrics and gynaecology. The Dutch curriculum represents a practical example of how such a program could be developed. Several CBME curricular initiatives have now also begun across Canada.

Global Women's Health Education in Canadian Obstetrics and Gynaecology Residency Programs: A Survey of Program Directors and Senior Residents

OBJECTIVE To become culturally competent practitioners with the ability to care and advocate for vulnerable populations, residents must be educated in global health priorities. In the field of obstetrics and gynaecology, there is minimal information about global womens health (GWH) education and interest within residency programs. We wished to determine within obstetrics and gynaecology residency programs across Canada: (1) current GWH teaching and support, (2) the importance of GWH to residents and program directors, and (3) the level of interest in a national postgraduate GWH curriculum. METHODS We conducted an online survey across Canada of obstetrics and gynaecology residency program directors and senior obstetrics and gynaecology residents. RESULTS Of 297 residents, 101 (34.0%) responded to the survey and 76 (26%) completed the full survey. Eleven of 16 program directors (68.8%) responded and 10/16 (62.5%) provided complete responses. Four of 11 programs (36.4%) had a GWH curriculum, 2/11 (18.2%) had a GWH budget, and 4/11 (36.4%) had a GWH chairperson. Nine of 10 program directors (90%) and 68/79 residents (86.1%) felt that an understanding of GWH issues is important for all Canadian obstetrics and gynaecology trainees. Only 1/10 program directors (10%) and 11/79 residents (13.9%) felt that their program offered sufficient education in these issues. Of residents in programs with a GWH curriculum, 12/19 (63.2%) felt that residents in their program who did not undertake an international elective would still learn about GWH, versus only 9/50 residents (18.0%) in programs without a curriculum (P < 0.001). CONCLUSION Obstetrics and gynaecology residents and program directors feel that GWH education is important for all trainees and is currently insufficient. There is a high level of interest in a national postgraduate GWH educational module.

The Established Uses of Prostaglandins in Obstetrics

Abstract The prostaglandins PGF 2α and PGE 2 have been used in obstetric practice for the past three decades. Prostaglandin E 2 is widely given to soften and shorten the cervix for pre-induction cervical ripening in cases of a low Bishops score. Prostaglandin F 2α has a greater effect on uterine contractility, a feature that has made it useful in the management of post-partum uterine atony. The efficacy and safety of these prostaglandins will be reviewed, along with the evidence to support their use.

Maternal Hypothermia and Fetal Bradycardia Secondary to Infection: A Case Report and Literature Review

Abstract A 31-year-old woman developed hypothermia secondary to a right pyelonephritis at 34 weeks of pregnancy. Her temperature dropped to 35.1°C. At the same time, there was a sustained fetal bradycardia of 90 to 95 beats per minute. The management of maternal sepsis complicated by hypothermia and fetal bradycardia is discussed.

Twin Gestation: Evidence-based Outcome Analysis and Literature Review for Chromosomal Aneuploidy, Congenital Malformations, and Pregnancy Loss

Abstract Objective: to make recommendations about chromosamal aneuploidy, congenital malformations, and pregnancy loss in twin gestations to physicians providing prenatal care. Options: invasive prenatal testing (amniocentesis, chorionic villus sampling, cordocentesis), non-invasive testing (ultrasound, maternal serum screening) Outcomes: informed choice regarding invasive and non-invasive prenatal testing in twin gestations. Evidence: informatian obtained from well-designed cohort or case control analytic studies from more than one centre. Values: evidence-based methods and review of the literature were used. Benefits, risks, and costs: the collective risks of chromosomal aneuploidy in one of the fetuses in a twin pair is hypothetically increased. A woman who will be 32 years of age at the estimated date of delivery (EDD) with a twin gestation has a similar risk of a liveborn neonate with a chromosomal anomaly as a woman who will be 35 years of age at her EDD with a singleton pregnancy. For the total study group, the incidence of aneuploidy and pregnancies delivered at less than 28 weeks was 5.2 percent and 9.5 percent, respectively. Selective termination is a management option for a twin pregnancy with an abnormal fetus. Monozygotic twin pregnancies are at an increased risk for discordant malformations. Recommendation: a woman with a twin pregnancy has an increased risk that one or both twins will have chromosomal aneuploidy if the woman attains a maternal age of 32 on the expected date of delivery. This fetal chromosomal risk corresponds to the risk for a maternal age of 35 with a singleton pregnancy. A woman with a twin pregnancy should be made aware of this increased fetal chromosomal risk and be given a choice of invasive (amniocentesis, chorionic villus sampling, cordocentesis) or non-invasive (ultrasound, maternal serum screening) prenatal diagnosis and should be informed of the advantages, disadvantages, and risks of each choice. Procedure loss rates in twins are estimated at one percent while total pregnancy loss rates are increased due to background twin risks. Detailed ultrasound examination is required because of the increased risks of discordant malformation in monozygotic twins with normal chromosomes. Selective termination could be offered as a management option for a patient with an abnormal fetus in a twin pregnancy. Validation: no specific recommendations other than literature conclusions are available for twin gestations. Quality of evidence: II-2. Classification of recommendation: B.