Valérie I. Morin

Teratogenicity Associated With Pre-Existing and Gestational Diabete

OBJECTIVEnTo review the teratogenesis associated with pre-existing and gestational diabetes, to provide guidelines to optimize prevention and diagnosis of fetal abnormalities in women with diabetes, and to identify areas specific to fetal abnormalities and diabetes requiring further research.nnnOPTIONSnPre-conception counselling, pre-conception and first trimester folic acid supplementation, and glycemic control.nnnOUTCOMESnIncreased awareness of fetal abnormalities associated with pre-existing and gestational diabetes.nnnEVIDENCEnThe Cochrane Library and Medline were searched for English-language articles, published from 1990 to February 2005, relating to pre-existing and gestational diabetes and fetal abnormalities. Search terms included pregnancy, diabetes mellitus, pre-existing diabetes, type 1 diabetes, type 2 diabetes, insulin dependent diabetes, gestational diabetes, impaired glucose tolerance, congenital anomalies, malformations, and stillbirth. Additional publications were identified from the bibliographies of these articles as well as the Science Citation Index. All study types were reviewed. Randomized controlled trials were considered evidence of the highest quality, followed by cohort studies. Key studies and supporting data for each recommendation are summarized with evaluative comments and referenced.nnnVALUESnThe evidence collected was reviewed by the Genetics and Maternal Fetal Medicine Committees of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the criteria and classifications of the Canadian Task Force on Preventive Health Care.nnnRECOMMENDATIONSn1. Experimental studies suggest that hyperglycemia is the major teratogen in diabetic pregnancies, but other diabetes-related factors may also affect fetal outcomes. Further research using animal models is required to clarify the teratogenic factors associated with pre-existing and gestational diabetes. (II-3C) 2. Prospective and retrospective cohort studies have demonstrated an increased risk of congenital abnormalities with pre-existing diabetes. Further studies that include outcomes from first and second trimester pregnancy terminations, account for potential confounding variables, and use appropriate control groups are required. (II-2A) 3. Prospective and retrospective cohort studies have demonstrated an increased risk of congenital abnormalities with gestational diabetes. This observation is probably related to the inclusion of women with unrecognized type 2 diabetes. Clarification of the relationship between gestational diabetes and congenital abnormalities by studies that include outcomes from first and second trimester pregnancy terminations, account for potential confounding variables, and use appropriate control groups are required. (II-2A) 4. In some women, type 2 diabetes may be identified for the first time in pregnancy. Pre-conception recognition of women at high risk for type 2 diabetes and optimal glycemic control may reduce the risk of congenital anomalies. (II-2A) 5. Second generation sulfonylureas have not been associated with congenital abnormalities in human studies. The use of biguanides may be associated with other adverse perinatal outcomes. The use of other oral antihyperglycemic agents is not recommended in pregnancy. (II-2A) 6. The risk of congenital anomalies is increased in the offspring of obese women with diabetes. A healthy diet and regular exercise may help optimize pre-pregnancy weight and reduce the risk of congenital anomalies. (II-2A) 7. Accurate determination of gestational age is required in women with diabetes. Given the increased risk of congenital abnormalities, they should be offered appropriate biochemical and ultrasonographic screening and a detailed evaluation of fetal cardiac structures. (II-2A) 8. Women with diabetes should be offered pre-conception counselling with a multidisciplinary team to optimize general health and glycemic control and to review the risks of congenital anomalies. (II-2A) 9. A careful history should be obtained to identify other factors, such as a positive family history or advanced maternal age, that may further increase the risk of congenital structural or chromosomal abnormalities. (II-2A) 10. Pregnancy in women with diabetes should be planned. Good contraceptive advice and pre-pregnancy counselling are essential. Euglycemia should be maintained before and during pregnancy. (II-2A) 11. All women with diabetes should be counselled regarding intake of foods high in folic acid, folate-fortified foods, and appropriate folic acid supplementation of 4 to 5 mg per day pre-conceptionally and in the first 12 weeks of gestation. (II-2A) 12. A substantial number of women with diabetes do not access pre-conception care programs. Strategies are needed to improve access to such programs and to maximize interventions associated with improved pregnancy outcomes, such as folic acid use. (II-2A) VALIDATION: These guidelines have been reviewed by the Genetics Committee and the Maternal Fetal Medicine Committee of the SOGC. Final approval has been given by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.

Diagnosis and Management of Placenta Previa

OBJECTIVEnTo review the use of transvaginal ultrasound for the diagnosis of placenta previa and recommend management based on accurate placental localization.nnnOPTIONSnTransvaginal sonography (TVS) versus transabdominal sonography for the diagnosis of placenta previa; route of delivery,based on placenta edge to internal cervical os distance; in-patient versus out-patient antenatal care; cerclage to prevent bleeding; regional versus general anaesthesia; prenatal diagnosis of placenta accreta.nnnOUTCOMEnProven clinical benefit in the use of TVS for diagnosing and planning management of placenta previa.nnnEVIDENCEnMEDLINE search for placenta previa and bibliographic review.nnnBENEFITS, HARMS, AND COSTSnAccurate diagnosis of placenta previa may reduce hospital stays and unnecessary interventions.nnnRECOMMENDATIONSn1. Transvaginal sonography, if available, may be used to investigate placental location at any time in pregnancy when the placenta is thought to be low-lying. It is significantly more accurate than transabdominal sonography, and its safety is well established. (11-2A) 2. Sonographers are encouraged to report the actual distance from the placental edge to the internal cervical os at TVS, using standard terminology of millimetres away from the os or millimetres of overlap. A placental edge exactly reaching the internal os is described as 0 mm. When the placental edge reaches or overlaps the internal os on TVS between 18 and 24 weeks gestation (incidence 2-4%), a follow-up examination for placental location in the third trimester is recommended. Overlap of more than 15 mm is associated with an increased likelihood of placenta previa at term. (ll-2A) 3. When the placental edge lies between 20 mm away from the internal os and 20 mm of overlap after 26 weeks gestation, ultrasound should be repeated at regular intervals depending on the gestational age, distance from the internal os, and clinical features such as bleeding, because continued change in placental location is likely. Overlap of 20 mm or more at any time in the third trimester is highly predictive of the need for Caesarean section (CS). (llI-B) 4. The os-placental edge distance on TVS after 35 weeks gestation is valuable in planning route of delivery. When the placental edge lies > 20 mm away from the internal cervical os, women can be offered a trial of labour with a high expectation of success. A distance of 20 to 0 mm away from the os is associated with a higher CS rate, although vaginal delivery is still possible depending on the clinical circumstances. (ll-2A) 5. In general, any degree of overlap (> 0 mm) after 35 weeks is an indication for Caesarean section as the route of delivery. (ll-2A) 6. Outpatient management of placenta previa may be appropriate for stable women with home support, close proximity to a hospital, and readily available transportation and telephone communication. (ll-2C) 7. There is insufficient evidence to recommend the practice of cervical cerclage to reduce bleeding in placenta previa. (llI-D) 8. Regional anaesthesia may be employed for CS in the presence of placenta previa. (II-2B) 9. Women with a placenta previa and a prior CS are at high risk for placenta accreta. If there is imaging evidence of pathological adherence of the placenta, delivery should be planned in an appropriate setting with adequate resources. (II-2B) VALIDATION: Comparison with Placenta previa and placenta previa accreta: diagnosis and management. Royal College ofObstetricians and Gynaecologists, Guideline No. 27,October 2005.The level of evidence and quality of recommendations are described using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table).

Knowledge on Periconceptional Use of Folic Acid in Women of British Columbia

Objective: Our purpose was to evaluate the knowledge of folic acid and its use preconceptionally in women of British Columbia. Methods: The study was conducted at British Columbia Women’s Hospital in Vancouver, Canada, between April 15 and June 15, 1999. Pregnant women and women in the postpartum period were asked to complete a survey on folic acid. Results: In total, 1,004 women completed the questionnaire during the study period. Seventy-one percent of the women knew that vitamins could help prevent birth defects. Of those, 76.3% identified folic acid as the one vitamin specifically associated with reduction of birth defects. It was identified that 49.4% of all women took vitamins prior to pregnancy. Conclusions: Women in the population studied were relatively well informed about the benefits of folic acid, but less than 50% of them took vitamins prior to conception.

Familial hypokalemic periodic paralysis and wolff-parkinson-white syndrome in pregnancy

Purpose: To describe the anesthetic and obstetrical management of a pregnant patient with co-existing Familial Hypokalemic Periodic Paralysis (FHPP) and Wolff-Parkinson-White syndrome (WPW).Clinical Features: A 29 yr-old primigravida with FHPP and WPW presented to the antenatal clinic at 18 wk gestation, for consideration of her anesthetic and obstetrical management during labour and delivery. A plan was constructed to avoid the known precipitating factors of FHPP including carbohydrate loading, cold, mental stress and exercise, which could lead to acute attacks of weakness. She presented for induction of labour at 41 wk and three days. An epidural catheter was sited early in labour. The second stage was limited to less than one hour. She had a rotational forceps delivery for which the epidural was extended to provide anesthesia. A healthy male baby was delivered. The patient made an uncomplicated recovery and was discharged home on the second postnatal day. The peripartum potassium was kept within the normal range with intravenous as well as oral potassium supplementation. No arrhythmias were reported.Conclusion: Assessment of the patient at an early stage in her pregnancy allowed for a multidisciplinary approach to this patient and her medical problems. A plan was made to avoid known precipitating factors during labour, delivery and the postnatal period well in advance of her date of confinement, leading to a successful outcome for mother and child.RésuméObjectif: Décrire le traitement anesthésique et obstétrical d’une patiente enceinte atteinte d’une paralysie périodique hypokaliémique familiale (PPHF) et du syndrome de Wolff-Parkinson-White (WPW).Éléments cliniques: Une primigeste de 29 ans atteinte de PPHF et du syndrome de WPW a été vue à la clinique prénatale à 18 sem de grossesse pour que soit envisagé le déroulement anesthésique et obstétrical du travail et de l’accouchement. Cette planification visait à prévenir les facteurs déclenchants de la PPFH, comme la charge glucidique, le froid, le stress mental et l’exercice, qui pourraient entraîner une faiblesse aiguë. À 41 sem et 3 jrs de grossesse, on a procédé à l’induction du travail. On a placé un cathéter péridural tôt pendant le travail actif. Le deuxième stade a duré moins d’une heure. L’accouchement a nécessité une rotation par l’application de forceps et une extension de l’anesthésie. La patiente a donné naissance à un garçon en santé, a connu une récupération sans complications et a quitté l’hôpital le deuxième jour postnatal. Pendant la période périnatale, le potassium a été maintenu dans les limites de la normale grâce à des suppléments intraveineux et oraux. Aucune arythmie n’a été notée.Conclusion: L’évaluation de la grossesse à un stade précoce a permis le traitement multidisciplinaire de la patiente et de sa condition médicale. Le plan élaboré, bien avant la date prévue de l’accouchement, pour prévenir les facteurs déclenchants de la maladie pendant la période périnatale a mené à d’heureux résultats pour la mère et l’enfant.

Tératogénicité associée aux diabètes gestationnel et préexistant

Resume Objectif Etudier la teratogenicite associee aux diabetes gestationnel et preexistant, fournir des lignes directrices en vue doptimiser la prevention et le diagnostic des anomalies foetales chez les femmes diabetiques, et identifier les domaines particuliers de lassociation entre les anomalies foetales et le diabete qui necessitent la tenue dautres recherches. Options Counseling preconception, supplementation en acide folique avant la grossesse et pendant le premier trimestre, et maitrise de la glycemie. Issues Sensibilisation accrue aux anomalies foetales associees aux diabetes gestationnel et preexistant. Resultats Des recherches ont ete menees dans Cochrane Library et Medline en vue den tirer les articles, rediges en anglais et publies entre 1990 et fevrier 2005, traitant des anomalies foetales et des diabetes gestationnel et preexistant. Parmi les termes de recherche, on trouvait ce qui suit : pregnancy, diabetes mellitus, pre-existing diabetes, type 1 diabetes, type 2 diabetes, insulin dependent diabetes, gestational diabetes, impaired glucose tolerance, congenital anomalies, malformations et stillbirth. Des publications additionnelles ont ete identifiees a partir des bibliographies de ces articles, ainsi qua partir du Science Citation Index . Lanalyse a porte sur tous les types detude. Les essais comparatifs randomises arrivaient en tete de liste en matiere de qualite des resultats; les etudes de cohorte arrivaient au deuxieme rang a ce chapitre. Les etudes cles et les donnees justificatives pour chacune des recommandations sont resumees au moyen de commentaires devaluation et font lobjet de references. Valeurs Les donnees recueillies ont ete analysees par les comites sur la genetique et sur la medecine foeto-maternelle de la Societe des obstetriciens et gynecologues du Canada (SOGC), et quantifiees au moyen des classifications et des criteres etablis par le Groupe detude canadien sur les soins de sante preventifs. Recommandations 1.Bien que les etudes experimentales laissent entendre que lhyperglycemie constitue le principal agent teratogene dans le cadre des grossesses diabetiques, dautres facteurs lies au diabete peuvent egalement affecter les issues foetales. Dautres recherches faisant appel a des modeles animaux saverent requises pour clarifier les facteurs teratogenes qui sont associes aux diabetes gestationnel et preexistant. (II-3C) 2.Des etudes de cohorte prospectives et retrospectives ont demontre lexistence dune hausse du risque danomalies congenitales en presence dun diabete preexistant. Dautres etudes incluant les issues des interruptions de grossesse au cours du premier et du deuxieme trimestre, neutralisant leffet de variables parasites potentielles et utilisant des groupes temoins appropries saverent requises. (II-2A) 3.Des etudes de cohorte prospectives et retrospectives ont demontre quune hausse du risque danomalies congenitales etait associee au diabete gestationnel. Cette constatation est probablement associee a linclusion des femmes presentant un diabete de type 2 passe inapercu. La clarification de la relation entre le diabete gestationnel et les anomalies congenitales au moyen detudes incluant les issues des interruptions de grossesse au cours du premier et du deuxieme trimestre, neutralisant leffet de variables parasites potentielles et utilisant des groupes temoins appropries savere requise. (II-2A) 4.Chez certaines femmes, il est possible que la presence dun diabete de type 2 soit constatee pour la premiere fois au cours de la grossesse. Lidentification preconception des femmes courant des risques eleves de presenter un diabete de type 2 et la mise en oeuvre dune maitrise glycemique optimale pourraient entrainer la baisse du risque danomalies congenitales. (II-2A) 5.Les sulfonylurees de deuxieme generation nont pas ete associees a des anomalies congenitales dans le cadre detudes menees chez lhomme. Lutilisation de biguanides pourrait etre associee a dautres issues perinatales indesirables. Lutilisation dautres agents antihyperglycemiques oraux nest pas recommandee au cours de la grossesse. (II-2A) 6.Le risque danomalies congenitales est accru chez la progeniture des femmes obeses diabetiques. Un regime alimentaire sain et la pratique reguliere dexercices peuvent contribuer a optimiser le poids pregrossesse et a reduire le risque danomaliescongenitales. (II-2A) 7.La determination precise de lâge gestationnel savere requise chez les femmes diabetiques. Compte tenu de la hausse du risque danomalies congenitales, ces femmes devraient se voir offrir un depistage biochimique et echographique approprie, ainsi quune evaluation detaillee des structures cardiaques foetales. (II-2A) 8.Les femmes diabetiques devraient se voir offrir des services de counseling preconception par une equipe multidisciplinaire, afin doptimiser leur sante generale et leur maitrise glycemique, et danalyser leur risque danomalies congenitales. (II-2A) 9.Le fournisseur de soins devrait sassurer de consigner rigoureusement les antecedents de la patiente afin didentifier dautres facteurs (tels que des antecedents familiaux positifs ou un âge maternel avance) pouvant aggraver davantage le risque danomalies structurelles ou chromosomiques congenitales. (II-2A) 10.Chez les femmes diabetiques, la grossesse devrait faire lobjet dune planification. Loffre de services adequats de counseling au sujet de la contraception et de la periode preconception savere essentielle. Leuglycemie devrait etre maintenue avant et pendant la grossesse. (II-2A) 11.Toutes les femmes diabetiques devraient beneficier de conseils au sujet de la consommation daliments a teneur elevee en acide folique et fortifies au folate, et de ladoption dune supplementation appropriee en acide folique (de 4 a 5 mg par jour) pendant la periode preconception et pendant les 12 premieres semaines de gestation. (II-2A) 12.Un nombre important de femmes diabetiques ne profitent pas des programmes de soins preconception offerts. Des strategies saverent requises pour ameliorer lacces a ces programmes et pour maximiser les interventions associees a lamelioration des issues de grossesse, telles que lutilisation dacide folique. (II-2A) Validation La presente directive clinique a ete examinee par les comites sur la genetique et sur la medecine foeto-maternelle de la SOGC. Lapprobation finale a ete accordee par le comite executif et le Conseil de la Societe des obstetriciens et gynecologues du Canada. Commanditaire La Societe des obstetriciens et gynecologues du Canada

Diagnostic et prise en charge du placenta praevia

Resume Objectif Examiner le recours a lechographie transvaginale aux fins du diagnostic du placenta praevia et recommander une prise en charge fondee sur une localisation precise du placenta. Options Echographie transvaginale (ETV) ou echographie transabdominale, en ce qui a trait au diagnostic du placenta praevia; voie daccouchement, en fonction de la distance separant le pourtour du placenta et lorifice cervical interne; soins prenatals a lhopital ou en clinique externe; cerclage afin de prevenir lhemorragie; anesthesie locale ou generale; diagnostic prenatal du placenta accreta. Issue Avantage clinique eprouve en ce qui concerne le recours a lETV pour le diagnostic et la planification de la prise en charge du placenta praevia. Resultats Recherche menee dans MEDLINE au moyen du terme placenta previa et analyse bibliographique. Avantages, desavantages et couts Lobtention dun diagnostic precis du placenta praevia pourrait entrainer une diminution de la duree dhospitalisation et du nombre dinterventions inutiles. Recommandations 1.Lechographie transvaginale, lorsque disponible, peut etre utilisee pour determiner lemplacement du placenta en tout temps pendant la grossesse, lorsque lon soupconne avoir affaire a un placenta bas. Elle est considerablement plus precise que lechographie transabdominale et son innocuite est bien etablie. (11–2A) 2.On incite les echographistes a signaler, au moment de lETV, la distance exacte separant le pourtour placentaire et lorifice cervical interne en ayant recours a la terminologie standard (millimetres decart par rapport a lorifice ou millimetres de chevauchement). La situation dans laquelle le pourtour placentaire atteint exactement lorifice interne est decrite sous forme dune distance de 0mm. Lorsque, au moment de lETV menee entre la 18 e et la 24 e semaine de gestation, le pourtour placentaire atteint lorifice cervical interne ou empiete sur ce dernier (incidence se situant entre 2 % et 4 %), la tenue dun examen de suivi visant a determiner lemplacement du placenta au troisieme trimestre est recommandee. Un chevauchement superieur a 15mm est associe a une hausse de la probabilite dun placenta praevia a terme. (ll-2A) 3.Lorsque le pourtour placentaire se situe a entre 20mm decart par rapport a lorifice interne et 20mm de chevauchement apres la 26 e semaine de gestation, lechographie devrait etre repetee a intervalles reguliers (en fonction de lâge gestationnel, de la distance par rapport a lorifice interne et de caracteristiques cliniques telles que lhemorragie), et ce, puisquil est probable que la position du placenta continue devoluer. Un chevauchement de 20mm ou plus, a quelque moment que ce soit au cours du troisieme trimestre, est grandement predictif de la necessite davoir recours a la CS. (ll-B) 4.La distance orifice-pourtour placentaire, au moment de lETV menee apres la 35 e semaine de gestation, savere utile pour la planification de la voie daccouchement. Lorsque le pourtour placentaire se situe a > 20mm decart par rapport a lorifice cervical interne, les femmes peuvent se voir offrir un essai de travail, lequel presente alors une forte probabilite de reussite. Une distance de 20 a 0mm decart par rapport a lorifice est associee a un taux accru de CS; cependant, en fonction des circonstances cliniques presentes, laccouchement vaginal demeure possible. (ll-2A) 5.En general, apres la 35 e semaine de gestation, la presence de quelque degre de chevauchement (> 0mm) que ce soit constitue une indication pour le recours a la cesarienne a titre de voie daccouchement. (ll-2A) 6.La prise en charge du placenta praevia en clinique externe peut saverer appropriee dans le cas des femmes stables beneficiant dun soutien a la maison, demeurant a proximite immediate dun hopital et pouvant facilement et rapidement avoir acces a des moyens de transport et de communication telephonique. (ll-2C) 7.Nous ne disposons pas de donnees suffisantes pour recommander la pratique du cerclage cervical en vue de reduire les saignements en presence dun placenta praevia. (ll-D) 8.Lorsque lon doit effectuer une CS en raison dun placenta praevia, il est possible davoir recours a une anesthesie regionale. (II-2B) 9.Les femmes qui presentent un placenta praevia et qui ont deja subi une CS courent un risque accru de placenta accreta. En presence de resultats dimagerie indiquant une adherence pathologique du placenta, les fournisseurs de soins devraient faire en sorte de proceder a laccouchement au sein dun milieu approprie dote de ressources adequates. (II-2B) Validation Comparaison avec Placenta previa and placenta previa accreta: diagnosis and management , Royal College of Obstetricians and Gynaecologists, directive clinique n° 27, octobre 2005. La qualite des resultats et la classification des recommandations sont decrites au moyen des criteres et des categories etablis par le Groupe detude canadien sur les soins de sante preventifs (Tableau).

Post-menopausal Surrogate Motherhood: A Case Report

Abstract A 58-year-old post-menopausal women was a surrogate mother. She developed severe pre-eclampsia at 35 weeks of pregnancy and was delivered by Caesarean section. Postmenopausal motherhood is a controversial subject. The risk of obstetrical complications (gestational hypertension and diabetes) is high in women over 50. Their care is complex and should be multidisciplinary.

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.