Stephanie Klam

Incidence, Indications, and Predictors of Adverse Outcomes of Postpartum Hysterectomies: 20-Year Experience in a Tertiary Care Centre

OBJECTIVE Postpartum hysterectomy is an uncommon yet serious obstetric procedure associated with maternal morbidity and mortality. The objectives of our study were to assess the incidence of and indications for PH and to identify predictors of massive hemorrhage and coagulopathy. METHODS We conducted a retrospective cohort study on all cases of PH performed at the Jewish General Hospital, McGill University, between 1992 and 2011. Data were collected from individual patient charts and logistics regression models were used to evaluate predictors of adverse events. RESULTS Over a 20-year study period, there were 76 938 live births and 67 postpartum hysterectomies for an overall incidence of 0.87/1000. Although overall PH rates increased over time predominantly because of increasing rates of planned PH for placental abnormalities, there was a decrease in unplanned emergency postpartum hysterectomies. The main indications for PH were abnormal placentation (64.2%) and postpartum hemorrhage (26.9%). In adjusted analysis, the risk of requiring massive blood transfusion was increased when PH was performed after vaginal delivery or Caesarean section (OR 102.1; 95% CI 4.22 to 2468) and in association with postpartum hemorrhage (OR 9.1; 95% CI 1.3 to 64.3). The risk of massive hemorrhage was lower if occlusive balloons were placed antenatally in the uterine arteries (OR 0.13; 95% CI 0.03 to 0.68) and if PH was performed by a dedicated experienced surgeon (OR 0.23; 95% CI 0.06 to 0.86). CONCLUSION Although overall rates of PH are increasing, antenatal recognition of placental pathologies have resulted in fewer postpartum hysterectomies being done as emergencies. The use of occlusive balloons in the uterine arteries and having the procedure performed by a dedicated surgeon skilled in performing postpartum hysterectomy can reduce overall serious morbidity.

Pregnancy outcomes in women with bariatric surgery as compared with morbidly obese women

Abstract Objective: Pregnancies among morbidly obese women are associated with serious adverse maternal and neonatal outcomes. Our study objective is to evaluate the effect of bariatric surgery on obstetrical outcomes. Methods: We carried out a retrospective cohort study using the healthcare cost and utilization project – Nationwide Inpatient Sample from 2003 to 2011 comparing outcome of births among women who had undergone bariatric surgery with births among women with morbid obesity. Logistic regression was used to estimate the adjusted effect of bariatric surgery on maternal and newborn outcomes. Results: There were 8 475 831 births during the study period (221 580 (2.6%) in morbidly obese women and 9587 (0.1%) in women with bariatric surgery). Women with bariatric surgery were more likely to be Caucasian and ≥35 years old as compared with morbidly obese women. As compared with women with morbid obesity, women with bariatric surgery had lower rates of hypertensive disorders, premature rupture of membrane, chorioamnionitis, cesarean delivery, instrumental delivery, postpartum hemorrhage, and postpartum infection. Induction of labor, postpartum blood transfusions, venous thromboembolisms, and intrauterine fetal growth restriction were more common in the bariatric surgery group. There were no differences observed in preterm births, fetal deaths, or reported congenital anomalies. Conclusion: In general, women who undergo bariatric surgery have improved pregnancy outcomes as compared with morbidly obese women. However, the bariatric surgery group was more likely to have venous thromboembolisms, to require a blood transfusion, to have their labor induced and to experience fetal growth restriction.

Understanding factors affecting collaboration between midwives and other health care professionals in a birth center and its affiliated Quebec hospital: a case study

BackgroundA better understanding of the processes of collaboration between midwives who work in the birthing centers, and hospital-based obstetricians, family physicians and nurses may promote cooperation among professionals providing maternity care in both institutions. The aim of this research was to explore the barriers and facilitators of the interprofessional and interorganizational collaboration between midwives in birthing centers and other health care professionals in hospitals in Quebec.MethodsA case study design was adopted. Data were collected through semi-structured interviews with midwives, multidisciplinary professionals and administrators, through direct observation of activities in maternity units and field notes, and a variety of organizational and policy documents and archives. A qualitative thematic analysis method was used for analyzing transcribed verbatim.ResultsThe study suggests the close intertwinement between interactional, organizational and systemic factors in regard to barriers and opportunities for collaboration between midwives in birthing centers, and physicians and nurses in hospitals in Quebec. At interactional level, our findings show a conflict in scope of midwifery practice, myth about midwives, pre-judgment, and lack of communication skills between health care providers in the studied birthing center and hospital. At the organizational level, this investigation shows that although midwives have complete access to the hospital with which a formal agreement was signed, they were not integrated in hospital because of lack of interest of midwives and differences in philosophy and scope of practice among healthcare professionals as well as the culture of organizations. At a systemic level, in spite of excessive demand for midwifery care, there are not enough midwives to cover these demands.ConclusionMaternity care professionals require taking a collaborative approach in working and the boundaries of responsibility need to be redrawn. The inter-professional collaborative work between midwives and other maternity care professionals is crucial to improve access and women’s choices for maternity care in Canada. Although having collaborative and multidisciplinary teamwork is a goal of maternity care systems, it is hard to achieve.

Prenatal and postnatal features of mesenchymal hamartoma of the chest wall: case report and literature review

Mesenchymal hamartoma of the chest wall is a rare, benign chondro-osseous tumor of the bone. Although it most commonly presents at birth or soon after, prenatal detection is rare. We report a case of prenatally detected mesenchymal hamartoma, and provide the rationale, details, and outcomes of our management. The literature is reviewed, with particular attention to prenatal detection and postnatal management options.

Expectant Parents’ Understanding of the Implications and Management of Fever in the Neonate

Objective We estimated the extent to which Canadian expectant parents would seek medical care in a febrile neonate (age 30 days or less). We also evaluated expectant parents’ knowledge of signs and symptoms of fever in a neonate, and explored the actions Canadian expectant parents would take to optimize the health of their child. Methods We conducted a cross-sectional survey of a sample of expectant parents from a large urban center in Canada. We recruited participants from waiting rooms in an obstetrical ultrasound clinic located in an urban tertiary care hospital in Montreal, Canada. We asked participants nine questions about fever in neonates including if, and how, they would seek care for their neonate if they suspected he/she were febrile. Results Among the 355 respondents, (response rate 87%) we found that 75% of parents reported that they would take their febrile neonate for immediate medical assessment, with nearly one fifth of the sample reporting that they would not seek medical care. We found no significant associations between the choice to seek medical care and expectant parents socio-demographic characteristics. Conclusions Despite universal access to high quality health care in Canada, our study highlights concerning gaps in the knowledge of the care of the febrile infant in one fifth of expectant parents. Physicians and health providers should strive to provide early education to expectant parents about how to recognize signs of fever in the neonate and how best to seek medical care. This may improve neonatal health outcomes in Canada.

Effect of Uterine Cavity Sonographic Measurements on Medical Management Failure in Women With Early Pregnancy Loss

Medical management is commonly used among women with early pregnancy failure. The purpose of our study was to evaluate uterine content sonographic measurements for predicting medical management failure in early pregnancy loss.