Shia Salem

The Use of Magnetic Resonance Imaging in the Obstetric Patient

OBJECTIVE To review the biological effects and safety of magnetic resonance imaging (MRI) in the obstetric patient and to review procedural issues, indications, and contraindications for obstetrical MRI. OUTCOMES This guideline is intended to reassure patients and clinicians of the safety of MRI in pregnancy and to provide a framework for its use. EVIDENCE Published literature was retrieved through searches of PubMed or Medline in 2013 using controlled vocabulary and key words (e.g., MRI, safety, pregnancy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English and in French. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to July 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline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 quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). BENEFITS, HARMS, AND COSTS This article is intended to reassure obstetric care providers that if used in an appropriate manner without the use of contrast agents, MRI in the obstetrical patient is safe for mother and fetus in the second and third trimesters. Because obstetrical MRI is expensive and has limited availability in Canada, this clinical guideline is intended to encourage the judicious use of this resource. SUMMARY STATEMENTS: 1. Fetal magnetic resonance imaging is safe at 3.0 tesla or less during the second and third trimesters. (II-2) 2. It is safe to continue breastfeeding after receiving a gadolinium contrast agent. (III) RECOMMENDATIONS: 1. Use of magnetic resonance imaging during the first trimester of pregnancy should be restricted to maternal indications for which the information is considered clinically imperative. Inadvertent exposure to magnetic resonance imaging during the first trimester has not been associated with any long-term sequelae and should not raise clinical concern. (III-C) 2. Gadolinium contrast may be used in pregnant women when the benefits outweigh the potential risks. (III-C).

A Randomized, Controlled Trial of Heparin Versus Placebo Infusion to Prolong the Usability of Peripherally Placed Percutaneous Central Venous Catheters (PCVCs) in Neonates: The HIP (Heparin Infusion for PCVC) Study

BACKGROUND. Mechanical and infectious complications shorten the effective duration of peripherally inserted central venous catheters. Heparin use to prevent such complications and prolong the usability of peripherally inserted central venous catheters is inconclusive. OBJECTIVE. Our goal was to evaluate the effectiveness of heparin in prolonging the usability of peripherally inserted central venous catheters in neonates. DESIGN/METHODS. We performed a multicenter, randomized, controlled trial of heparin infusion (0.5 U/kg per hour) versus placebo for peripherally inserted central venous catheters in neonates. The primary outcome was duration of catheter use. Secondary outcomes were occlusion, catheter-related sepsis, thrombosis, and adverse effects of heparin. To detect a 168-hour (1-week) difference in the duration of catheter use, 192 patients were needed. Kaplan-Meier and Cox regression analyses were performed. RESULTS. A total of 201 neonates were enrolled (heparin group: n = 100; control group: n = 101). Baseline demographics were similar between the groups. Duration of catheter use was longer in the infants in the heparin versus the placebo group. Study center, gender, birth weight, and type and position of the catheter were not predictors of duration of catheter use. For those in the heparin versus the placebo group, the incidence of elective catheter removal (therapy completed) was 63% vs 42%, of occlusion was 6% vs 31%, of thrombosis was 20% vs 21%, and of catheter-related sepsis was 10% vs 6%, respectively. No adverse events were noted. CONCLUSIONS. Heparin infusion prolonged the duration of peripherally inserted central venous catheter usability, which permitted a higher percentage of neonates to complete therapy without increasing adverse effects.

Ultrasonographic Cervical Length Assessment in Predicting Preterm Birth in Singleton Pregnancies

OBJECTIVES To review (1) the use of ultrasonographic-derived cervical length measurement in predicting preterm birth and (2) interventions associated with a short cervical length. OUTCOMES Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions. EVIDENCE Published literature was retrieved through searches of PubMed and The Cochrane Library up to December 2009, using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, incompetent cervix, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. 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 and this guideline were reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made according to the guidelines developed by The Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the ultrasonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth. SPONSORS The Society of Obstetricians and Gynaecologists of Canada.

Guidelines for the Management of Vasa Previa

OBJECTIVES To describe the etiology of vasa previa and the risk factors and associated condition, to identify the various clinical presentations of vasa previa, to describe the ultrasound tools used in its diagnosis, and to describe the management of vasa previa. OUTCOMES Reduction of perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short-term and long-term maternal morbidity and mortality. EVIDENCE Published literature on randomized trials, prospective cohort studies, and selected retrospective cohort studies was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary (e.g., selected epidemiological studies comparing delivery by Caesarean section with vaginal delivery; studies comparing outcomes when vasa previa is diagnosed antenatally vs. intrapartum) and key words (e.g., vasa previa). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated into the guideline to October 1, 2008. 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 from national and international medical specialty societies. VALUES The evidence collected was reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS The benefit expected from this guideline is facilitation of optimal and uniform care for pregnancies complicated by vasa previa. SPONSORS The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENT A comparison of women who were diagnosed antenatally and those who were not shows respective neonatal survival rates of 97% and 44%, and neonatal blood transfusion rates of 3.4% and 58.5%, respectively. Vasa previa can be diagnosed antenatally, using combined abdominal and transvaginal ultrasound and colour flow mapping; however, many cases are not diagnosed, and not making such a diagnosis is still acceptable. Even under the best circumstances the false positive rate is extremely low. (II-2). RECOMMENDATIONS 1. If the placenta is found to be low lying at the routine second trimester ultrasound examination, further evaluation for placental cord insertion should be performed. (II-2B) 2. Transvaginal ultrasound may be considered for all women at high risk for vasa previa, including those with low or velamentous insertion of the cord, bilobate or succenturiate placenta, or for those having vaginal bleeding, in order to evaluate the internal cervical os. (II-2B) 3. If vasa previa is suspected, transvaginal ultrasound colour Doppler may be used to facilitate the diagnosis. Even with the use of transvaginal ultrasound colour Doppler, vasa previa may be missed. (II-2B) 4. When vasa previa is diagnosed antenatally, an elective Caesarean section should be offered prior to the onset of labour. (II-1A) 5. In cases of vasa previa, premature delivery is most likely; therefore, consideration should be given to administration of corticosteroids at 28 to 32 weeks to promote fetal lung maturation and to hospitalization at about 30 to 32 weeks. (II-2B) 6. In a woman with an antenatal diagnosis of vasa previa, when there has been bleeding or premature rupture of membranes, the woman should be offered delivery in a birthing unit with continuous electronic fetal heart rate monitoring and, if time permits, a rapid biochemical test for fetal hemoglobin, to be done as soon as possible; if any of the above tests are abnormal, an urgent Caesarean section should be performed. (III-B) 7. Women admitted with diagnosed vasa previa should ideally be transferred for delivery in a tertiary facility where a pediatrician and blood for neonatal transfusion are immediately available in case aggressive resuscitation of the neonate is necessary. (II-3B) 8. Women admitted to a tertiary care unit with a diagnosis of vasa previa should have this diagnosis clearly identified on the chart, and all health care providers should be made aware of the potential need for immediate delivery by Caesarean section if vaginal bleeding occurs. (III-B).

Adnexal masses in the pregnant patient: a diagnostic and management challenge.

Ultrasound is a valuable diagnostic tool, which can be used to stratify pregnant women with adnexal masses into a conservative management protocol versus those that require further diagnostic and management decisions. Familiarity with the natural history and sonographic features of common adnexal lesions, such as simple cysts, hemorrhagic cysts, endometriomas, mature cystic teratomas, and ovarian conditions specific to pregnancy, may permit stratification of patients into management protocols. The goal of ultrasound evaluation in the pregnant patient with an adnexal mass is to identify those patients in whom conservative management is appropriate versus those who require more immediate interventions such as surgery. The risk of surgical interventions needs to be balanced against the potential risks of nonintervention, which may include torsion, rupture, hemorrhage, or the rare spread of a malignant cancer. Atypical features or persistent large lesions should initiate a multidisciplinary team approach to optimize diagnostic and management strategy. Acute symptoms may precipitate emergency intervention at any point in the pregnancy. We will present a diagnostic and management algorithm based on clinical symptoms, timing of detection, natural history, and sonographic features of adnexal masses in pregnancy.

Initial Evaluation and Referral Guidelines for Management of Pelvic/Ovarian Masses

OBJECTIVES To optimize the management of adnexal masses and to assist primary care physicians and gynaecologists determine which patients presenting with an ovarian mass with a significant risk of malignancy should be considered for gynaecologic oncology referral and management. OPTIONS Laparoscopic evaluation, comprehensive surgical staging for early ovarian cancer, or tumour debulking for advanced stage ovarian cancer. OUTCOMES To optimize conservative versus operative management of women with possible ovarian malignancy and to optimize the involvement of gynaecologic oncologists in planning and delivery of treatment. EVIDENCE Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified by searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. RECOMMENDATIONS 1. Primary care physicians and gynaecologists should always consider the possibility of an underlying ovarian cancer in patients in any age group who present with an adnexal or ovarian mass. (II-2B) 2. Appropriate workup of a perimenopausal or postmenopausal woman presenting with an adnexal mass should include evaluation of symptoms and signs suggestive of malignancy, such as persistent pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating. In addition, CA125 measurement should be considered. (II-2B) 3. Transvaginal or transabdominal ultrasound examination is recommended as part of the initial workup of a complex adnexal/ovarian mass. (II-2B) 4. Ultrasound reports should be standardized to include size and unilateral/bilateral location of the adnexal mass and its possible origin, thickness of septations, presence of excrescences and internal solid components, vascular flow distribution pattern, and presence or absence of ascites. This information is essential for calculating the risk of malignancy index II score to identify pelvic mass with high malignant potential. (IIIC) 5. Patients deemed to have a high risk of an underlying malignancy should be reviewed in consultation with a gynaecologic oncologist for assessment and optimal surgical management. (II-2B).

Fetal Sex Determination and Disclosure

The Supreme Court of Canada (McInerney v. MacDonald 1992) concluded that a patient is entitled to examine and copy from his or her medical record all information the physician considered in administering advice or treatment.2 The physician must justify denying access to that record on the basis that doing so would not be in the patient’s best interest. On the basis of this ruling, it is legally difficult to defend nondisclosure. Disclosure of fetal sex upon request respects a woman’s rightful autonomy over personal health information. Those who oppose fetal sex determination and disclosure have concerns about risk for error, the time involved in making a determination of fetal sex, and that the information may lead women to abort pregnancies when the fetus is not the wanted sex. The risk for error is estimated to be less than 3%, but prospective parents should be made aware of this possibility with disclosure.3 There is no evidence that fetal sex determination during a complete obstetric ultrasound will extend the examination time.3 A small number of pregnant women may consider abortion when the fetus is the unwanted sex; however, this is best addressed by the health professionals who are providing care for these women. Diagnostic imaging units that prefer to maintain a policy of nondisclosure of fetal sex should include the information in their reports. This would allow the referring physicians or midwives to disclose the fetal sex at their patients’ request. In summary, SOGC recommends that fetal genitalia be examined as a part of the routine second trimester obstetric ultrasound and that this examination not be prolonged or repeated if no abnormalities are seen but sex determination is inconclusive. If fetal sex has been determined, a patient’s request for disclosure should be respected, either directly or in a report to the referring health professional.

Joint SOGC/CAR Policy Statement on Non-medical Use of Fetal Ultrasound

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the SOGC. This joint policy statement has been prepared by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada and the Point of Care Ultrasound Working Group of the Canadian Association of Radiologists and approved by the Executive and Council of the Society of Obstetrics and Gynaecology of Canada and the Board of Directors of the Canadian Association of Radiologists.

Utilisation non médicale de l’échographie fœtale

La présente déclaration de principe commune a été rédigée par le comité d’imagerie diagnostique de la Société des obstétriciens et gynécologues du Canada, et le Groupe de travail sur l’échographie au point de service de l’Association canadienne des radiologistes, et approuvée par le comité exécutif et le Conseil de la Société des obstétriciens et gynécologues du Canada, et le conseil d’administration de l’Association canadienne des radiologistes.

Joint CAR/SOGC Statement on Performing Ultrasound Examinations of the Female Pelvis

These joint guidelines of the Canadian Association of Radiologists (CAR) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) are not rules, but an attempt to define principles of guiding practices that should generally produce optimal radiological care. The physician may deviate from existing guidelines as determined by the individual patient and available resources. Adherence to these CAR/SOGC practice guidelines will not assure a successful outcome in every situation. The practice guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The practice guidelines are not intended to establish a legal standard of care or conduct, and deviation from practice guidelines does not, in and of itself, indicate or imply that such medical practice is below an acceptable level of care. The ultimate judgment regarding the propriety of any specific procedure or course of conduct must be made by the physician and medical physicist in light of all circumstances