Publications by authors named "Noor Ladhani"

21 Publications

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Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities.

J Obstet Gynaecol Can 2021 Feb 22. Epub 2021 Feb 22.

Calgary, AB.

Objective: To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada.

Target Population: This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline.

Outcomes: Safe and compassionate care for people with physical disabilities who are giving birth.

Benefits, Harms, And Costs: Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth.

Evidence: A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed.

Validation Methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

Intended Audience: Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

Recommendations:
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http://dx.doi.org/10.1016/j.jogc.2021.02.111DOI Listing
February 2021

Directive clinique n 416 : Soins pendant l'accouchement et la période post-partum chez les personnes ayant un handicap physique.

J Obstet Gynaecol Can 2021 Feb 20. Epub 2021 Feb 20.

Calgary, Alb.

Objectif: Décrire les pratiques fondées sur des données probantes en matière de prise en charge des soins pendant l'accouchement et la période post-partum chez les personnes ayant un handicap physique au Canada.

Population Cible: La présente directive clinique aborde les besoins des personnes ayant un handicap physique en mettant l'accent sur les problèmes de santé qui affectent la force et la mobilité, ainsi que sur ceux qui touchent les fonctions ou structures neurologiques ou musculosquelettiques. Bien que certains aspects de cette directive puissent s'appliquer aux personnes ayant une déficience intellectuelle, un trouble neurodéveloppemental ou un handicap sensoriel (p. ex., perte auditive ou visuelle) seulement, les besoins de cette population sortent du cadre de la présente directive. RéSULTATS: Prestation de soins sûrs et empathiques aux personnes parturientes ayant un handicap physique. BéNéFICES, RISQUES ET COûTS: La mise en œuvre de la présente directive permettra aux fournisseurs de soins de santé de mieux connaître les complications particulières que peuvent présenter les personnes ayant un handicap physique pendant l'accouchement et la période post-partum, ce qui augmentera la probabilité d'un accouchement sécuritaire. DONNéES PROBANTES: Une revue de la littérature a été effectuée à l'aide des bases de données MEDLINE (474), Embase(36) et le Cochrane Central Register of Controlled Trials (CENTRAL; 28). Les résultats ont été filtrés pour obtenir des études observationnelles, des revues systématiques, des méta-analyses et des directives publiées en anglais depuis 2013. Les références de ces articles ont également été passées en revue. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la solidité des recommandations en utilisant la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PUBLIC VISé: Spécialistes en médecine fœto-maternelle, obstétriciens, médecins de famille, infirmières, sages-femmes, neurologues, physiatres et autres professionnels qui donnent des soins aux personnes ayant un handicap physique.
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http://dx.doi.org/10.1016/j.jogc.2021.02.112DOI Listing
February 2021

Impact of red blood cell alloimmunization on fetal and neonatal outcomes: A single center cohort study.

Transfusion 2020 Nov 7;60(11):2537-2546. Epub 2020 Sep 7.

Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.

Background: Alloimmunization can impact both the fetus and neonate.

Study Objectives: (a) calculate the incidence of clinically significant RBC isoimmunization during pregnancy, (b) review maternal management and neonatal outcomes, (c) assess the value of prenatal and postnatal serological testing in predicting neonatal outcomes.

Study Design And Methods: A retrospective audit of consecutive alloimmunized pregnancies was conducted. Data collected included demographics, clinical outcomes, and laboratory results. Outcomes included: incidence of alloimmunization; outcomes for neonates with and without the cognate antigen; and sensitivity and specificity of antibody titration testing in predicting hemolytic disease of the fetus and newborn (HDFN).

Results: Over 6 years, 128 pregnant women (0.4%) were alloimmunized with 162 alloantibodies; anti-E was the most common alloantibody (51/162; 31%). Intrauterine transfusions (IUTs) were employed in 2 (3%) of 71 mothers of cognate antigen positive (CoAg+) neonates. Of 74 CoAg+ neonates, 58% required observation alone, 23% intensive phototherapy, 9% top up transfusion, and 3% exchange transfusion; no fetal or neonatal deaths occurred. HDFN was diagnosed in 28% (21/74) of neonates; anti-D was the most common cause. The sensitivity and specificity of the critical gel titer >32 in predicting HDFN were 76% and 75%, respectively (negative predictive value 95%; positive predictive value 36%). The sensitivity and specificity of a positive direct antiglobulin test (DAT) in predicting HDFN were 90% and 58%, respectively (NPV 97%; PPV 29%).

Conclusion: Morbidity and mortality related to HDFN was low; most alloimmunized pregnancies needed minimal intervention. Titers of >32 by gel warrant additional monitoring during pregnancy.
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http://dx.doi.org/10.1111/trf.16061DOI Listing
November 2020

N 369 - Prise en charge de la grossesse aprés une mortinaissance.

J Obstet Gynaecol Can 2018 12;40(12):1684-1700

Manchester (R.-U.).

Objectif: L'objectif principal de la présente déclaration de consensus est d'élaborer des énoncés de consensus qui guideront la pratique clinique et des recommandations pour les soins prénataux et les soins intrapartum, et les considérations psychosociales dont il faut tenir compte pour prendre soin des femmes enceintes ayant des antécédents de mortinaissance.

Utilisateurs Cibles: Les cliniciens participant à la prise en charge obstétrique des femmes ayant des antécédents de mortinaissance ou d'autres formes de décès périnatal.

Population Cible: Les femmes et les familles recevant des soins après une grossesse s'étant soldée par une mortinaissance ou une autre forme de décès périnatal. ÉVIDENCE: La présente directive clinique résume la littérature publiée et énonce un consensus général sur la prise en charge des grossesses suivant une mortinaissance ou un décès périnatal. Nous avons interrogé les bases de données MEDLINE, Embase et Cochrane au moyen des mots-clés : « previous stillbirth », « perinatal loss » et « subsequent pregnancy ». Nous avons ensuite étudié les résultats et lu les articles pertinents. Nous avons également consulté les références des articles retenus et les documents citant des études pertinentes. Les données ont ensuite été présentées pendant une réunion de consensus, et les énoncés ont été formulés. En raison du manque de données probantes, nous avons également consulté les cheminements de soins de cliniques spécialisées.

Validation: Le contenu et les lignes directrices ont été élaborés par les auteurs principaux en consultation avec les participants à la rencontre. Le Conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version finale avant publication. La qualité des données probantes a été évaluée au moyen des critères de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) [tableau 1]. L'interprétation des recommandations solides et conditionnelles est décrite dans le tableau 2. Le résumé des conclusions peut être fourni sur demande. AVANTAGES, INCONVéNIENTS, COûTS: Nous avons exploré une approche multidisciplinaire de prestation des soins prénataux et intrapartum aux femmes et aux familles ayant des antécédents de mortinaissance ou de décès périnatal. Bien qu'il manque de données probantes dans ce domaine, certains membres du groupe de travail fournissent ces soins à des femmes et à des familles dans plusieurs pays et nous ont fait part de leurs connaissances et de leurs expériences dans le but de guider les soins. MIS-à-JOUR: Une revue des données probantes sera menée cinq ans après la publication de la présente directive clinique afin d'évaluer si une mise à jour complète ou partielle s'impose. Cependant, si de nouvelles données probantes importantes sont publiées avant la fin du cycle de cinq ans, le processus pourrait être accéléré afin que certaines recommandations soient mises à jour rapidement.

Commanditaires: La présente directive clinique a été élaborée à l'aide de ressources financées par la Société des obstétriciens et gynécologues du Canada et le Programme pour les femmes et les bébés du Centre Sunnybrook des sciences et la santé tableau 1,2. DéCLARATIONS SOMMAIRES ET RECOMMANDATIONS.
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http://dx.doi.org/10.1016/j.jogc.2018.10.012DOI Listing
December 2018

No. 369-Management of Pregnancy Subsequent to Stillbirth.

J Obstet Gynaecol Can 2018 12;40(12):1669-1683

Manchester, United Kingdom.

Objective: The primary objective of this consensus statement is to develop consensus statements to guide clinical practice and recommendations for antenatal care, intrapartum care, and the psychosocial considerations necessary in the care of pregnant women with a history of stillbirth.

Intended Users: Clinicians involved in the obstetric management of women with a history of stillbirth or other causes of perinatal loss TARGET POPULATION: Women and families presenting for care following a pregnancy affected by stillbirth or other causes perinatal loss EVIDENCE: This document presents a summary of the literature and a general consensus on the management of pregnancies subsequent to stillbirth and perinatal loss. Medline, EMBASE, and Cochrane databases were searched using the following key words: previous stillbirth, perinatal loss, subsequent pregnancy. The results were then studied, and relevant papers were reviewed. The references of the reviewed studies were also searched, as were documents citing pertinent studies. The evidence was then presented at a consensus meeting, and statements were developed. Due to lack of evidence, care pathways of specialty clinics were consulted.

Validation Methods: The content and guidelines were developed by the primary authors in consultation with the meeting attendees. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Table 1). The interpretation of strong and weak recommendations is described in Table 2. The Summary of Findings is available upon request.

Benefits, Harms, And Costs: A multidisciplinary approach in the provision of antenatal and intrapartum care to women and families with a history of stillbirth and perinatal loss was explored. While there is a lack of evidence in this area, members of the working group are providing care to women and families around the world and are sharing their knowledge and experience to help guide care.

Guideline Update: Evidence will be reviewed 5 years after publication to evaluate whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.

Sponsors: This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada and the Women and Babies Program at Sunnybrook Health Sciences Centre.

Recommendations:
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http://dx.doi.org/10.1016/j.jogc.2018.07.002DOI Listing
December 2018

Canadian Stroke Best Practice Consensus Statement: Acute Stroke Management during pregnancy.

Int J Stroke 2018 10 18;13(7):743-758. Epub 2018 Jul 18.

27 Heart and Stroke Foundation of Canada, Toronto, Canada.

The Canadian Stroke Best Practice Consensus Statement Acute Stroke Management during Pregnancy is the second of a two-part series devoted to stroke in pregnancy. The first part focused on the unique aspects of secondary stroke prevention in a woman with a prior history of stroke who is, or is planning to become, pregnant. This document focuses on the management of a woman who experiences an acute stroke during pregnancy. This consensus statement was developed in recognition of the need for a specifically tailored approach to the management of this group of patients in the absence of any broad-based, stroke-specific guidelines or consensus statements, which do not exist currently. The foundation for the development of this document was the concept that maternal health is vital for fetal well-being; therefore, management decisions should be based first on the confluence of two clinical considerations: (a) decisions that would be made if the patient wasn't pregnant and (b) decisions that would be made if the patient hadn't had a stroke, then nuanced as needed. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include initial emergency management, diagnostic imaging, acute stroke treatment, the management of hemorrhagic stroke, anesthetic management, post stroke management for women with a stroke in pregnancy, intrapartum considerations, and postpartum management. These statements are appropriate for healthcare professionals across all disciplines and system planners to ensure pregnant women who experience a stroke have timely access to both expert neurological and obstetric care.
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http://dx.doi.org/10.1177/1747493018786617DOI Listing
October 2018

Making it more safe for periviable breech infants: Author Response.

J Obstet Gynaecol Can 2018 04;40(4):404

Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON.

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http://dx.doi.org/10.1016/j.jogc.2018.01.010DOI Listing
April 2018

Canadian stroke best practice consensus statement: Secondary stroke prevention during pregnancy.

Int J Stroke 2018 06 24;13(4):406-419. Epub 2017 Nov 24.

27 282184 Heart and Stroke Foundation of Canada , Toronto, ON, Canada.

The Canadian Stroke Best Practice Consensus Statement: Secondary Stroke Prevention during Pregnancy, is the first of a two-part series devoted to stroke in pregnancy. This document focuses on unique aspects of secondary stroke prevention in a woman with a prior history of stroke or transient ischemic attack who is, or is planning to become, pregnant. Although stroke is relatively rare in this cohort, several aspects of pregnancy can increase stroke risk during or immediately after pregnancy. The rationale for the development of this consensus statement is based on the premise that stroke in this group requires a specifically-tailored management approach. No other broad-based, stroke-specific guidelines or consensus statements exist currently. Underpinning the development of this document was the concept that maternal health is vital for fetal wellbeing; therefore, management decisions should be based on the confluence of two clinical considerations: (a) decisions that would be made if the patient was not pregnant and (b) decisions that would be made if the patient had not had a stroke. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include general management considerations for secondary stroke prevention, the use of antithrombotics, blood pressure management, lipid management, diabetes care, and management for specific ischemic stroke etiologies in pregnancy. The focus is on maternal and fetal health while minimizing risks of a recurrent stroke, through counseling, monitoring, and the safety of select pharmacotherapy. These statements are appropriate for health care professionals across all disciplines.
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http://dx.doi.org/10.1177/1747493017743801DOI Listing
June 2018

Comparison of cesarean versus vaginal delivery of extremely preterm gestations in breech presentation: retrospective cohort study.

J Matern Fetal Neonatal Med 2019 Apr 20;32(7):1142-1147. Epub 2017 Nov 20.

a Department of Obstetrics and Gynecology , University of Toronto , Toronto , Canada.

As survival increases at earlier gestational ages, the optimal mode of delivery, especially in cases of breech presentation, is of increasing importance. The objective of this study was to compare outcomes of vaginal delivery (VD) and cesarean section (CS) births for infants in breech presentation at borderline viability. A retrospective chart review of live breech births between 23 + 0 and 25 + 6 weeks gestation at a tertiary university center from 2003 to 2013 was conducted. Those delivered vaginally were compared with those delivered by CS. Stillbirths and deliveries where no resuscitation was intended were removed from the analysis. Variables were compared using a Student -test (continuous), Mann-Whitney test (categorical), or a Chi-squared test (count). Logistic regression analysis was performed to further evaluate the results. Results with  < .05 were considered significant. One hundred seventy-six births were included, 36 VD and 140 CS. Baseline characteristics were similar between groups. Gestational age at delivery was significantly higher in CS deliveries (24.9 ± 0.6 versus 24.5 ± 0.7,  = .0007). The rate of neonatal death (23.6% versus 44.4%,  = .0127) was significantly lower in those born by CS. All other neonatal outcomes including Apgar scores at one and 5 min, cord gases, birth weight, length of stay in NICU, incidence of respiratory complications, and incidence of high-grade IVH demonstrated no significant differences. Logistic regression suggested that male sex, lower birth weight, and earlier gestational age are significantly associated with neonatal mortality. Thirty percent of uterine incisions were of the classical, high transverse or inverted-T types. The estimated blood loss was significantly higher in CS births (706.6 ± 226.4 versus 327.4 ± 174.1 mL,  < .0001), but there was no difference in the rate of blood transfusion. CS delivery of breech infants at borderline viability had a protective effect on neonatal mortality compared to VD depending on the regression model utilized. Infant sex, birth weight, and gestational age also contribute significantly to neonatal mortality. A prospective study of planned method of delivery is recommended to further explore this finding.
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http://dx.doi.org/10.1080/14767058.2017.1401997DOI Listing
April 2019

The incidence of pregnancy-related stroke: A systematic review and meta-analysis.

Int J Stroke 2017 10;12(7):687-697

2 University of Toronto, Toronto, Canada.

Background Stroke risk is increased during pregnancy, but estimates of pregnancy-related stroke incidence vary widely. Aims A systematic review and meta-analysis was conducted to assess the incidence of stroke during pregnancy and the puerperium. Ovid Medline, EMBASE, and ISI Web of Science were searched for studies published between 1990 and January 2017 reporting stroke incidence during pregnancy and postpartum, from defined pregnancy populations. Pooled analyses were conducted using a random effects approach and expressed as an incidence rate per 100,000 pregnancies, with 95% confidence intervals. Subgroup analyses of stroke type and timing were conducted. Summary of review Eleven studies met inclusion criteria. Variation in estimated rates was noted based on geography and study methodology. The pooled crude rate of pregnancy-related stroke was 30.0 per 100,000 pregnancies (95% confidence interval 18.8-47.9). The pooled crude rates from nonhemorrhagic stroke (arterial and cerebral venous sinus thrombosis) were 19.9 (95% confidence interval 10.7-36.9) and from hemorrhage 12.2 (95% confidence interval 6.4-23.2) per 100,000 pregnancies. For studies separately reporting cerebral venous sinus thrombosis, the rates were roughly equal between ischemic stroke (12.2, 95% confidence interval 6.7-22.2), cerebral venous sinus thrombosis (9.1, 95% confidence interval 4.3-18.9), and hemorrhage (12.2, 95% confidence interval 6.4-23.2). The crude stroke rate for antenatal/perinatal stroke was 18.3 (95% confidence interval 11.9-28.2), and for postpartum stroke was 14.7 (95% confidence interval 8.3-26.1). Conclusions Stroke affects 30.0 per 100,000 pregnancies, with ischemia, cerebral venous sinus thrombosis, and hemorrhage causing roughly equal numbers and with highest risk peripartum and postpartum. Organized approaches to the management of this high-risk population, informed by existing evidence from stroke and obstetrical care are needed.
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http://dx.doi.org/10.1177/1747493017723271DOI Listing
October 2017

No. 347-Obstetric Management at Borderline Viability.

J Obstet Gynaecol Can 2017 Sep;39(9):781-791

Toronto, ON.

Objective: The primary objective of this guideline was to develop consensus statements to guide clinical practice and recommendations for obstetric management of a pregnancy at borderline viability, currently defined as prior to 25+6 weeks.

Intended Users: Clinicians involved in the obstetric management of women whose fetus is at the borderline of viability.

Target Population: Women presenting for possible birth at borderline viability.

Evidence: This document presents a summary of the literature and a general consensus on the management of pregnancies at borderline viability, including maternal transfer and consultation, administration of antenatal corticosteroids and magnesium sulfate, fetal heart rate monitoring, and considerations in mode of delivery. Medline, EMBASE, and Cochrane databases were searched using the following keywords: extreme prematurity, borderline viability, preterm, pregnancy, antenatal corticosteroids, mode of delivery. The results were then studied, and relevant articles were reviewed. The references of the reviewed studies were also searched, as were documents citing pertinent studies. The evidence was then presented at a consensus meeting, and statements were developed.

Validation Methods: The content and recommendations were developed by the consensus group from the fields of Maternal-Fetal Medicine, Neonatology, Perinatal Nursing, Patient Advocacy, and Ethics. The quality of evidence was rated using criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework (reference 1). The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication.

Methods: The quality of evidence was rated using the criteria described in the Grading of Recommendations, Assessment, Development, and Evaluation methodology framework. The interpretation of strong and weak recommendations is described later. The Summary of Findings is available upon request.

Benefits, Harms, And Costs: A multidisciplinary approach should be used in counselling women and families at borderline viability. The impact of obstetric interventions in the improvement of neonatal outcomes is suggested in the literature, and if active resuscitation is intended, then active obstetric interventions should be considered.

Guideline Update: Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.

Sponsors: This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada and the Women and Babies Program at Sunnybrook Health Sciences Centre.

Recommendations:
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http://dx.doi.org/10.1016/j.jogc.2017.03.108DOI Listing
September 2017

Pregnancy Outcomes of Women Admitted to a Tertiary Care Centre with Short Cervix.

J Obstet Gynaecol Can 2017 May;39(5):328-334

Sunnybrook Health Sciences Centre, University of Toronto, Department of Obstetrics and Gynaecology, Toronto, ON. Electronic address:

Objective: Our aim was to characterize the management and outcome of women admitted to a tertiary high-risk obstetrics unit with a short cervix (≤25 mm), measured on transvaginal ultrasound (TVS), and to determine the latency period from diagnosis to delivery.

Methods: A retrospective chart review of women admitted to the High Risk Obstetrics Unit at Sunnybrook Health Sciences Centre between 2005-2011 with an ultrasound-identified short cervix was done.

Results: A total of 110 women admitted for a short cervix between 2005-2011 (N = 56 singletons; N = 54 twin gestations) met the inclusion criteria. The mean latency to delivery was 62.6 days; mean GA at delivery was 33.9 weeks. Following 7 and 14 days of admission, 5.5% and 11.8% of women had delivered, respectively. Preterm birth occurred in 70% of all women. Cervical length was a significant factor in predicting latency among singletons, whereas the length of stay in hospital for activity restriction was not.

Conclusions: Although many women with a short cervix delivered preterm, only a small proportion delivered within 2 weeks of admission. Although it is not clear whether inpatient management improves the pregnancy outcome, these findings have implications for both patient care and health resources.
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http://dx.doi.org/10.1016/j.jogc.2017.01.012DOI Listing
May 2017

Pregnancy subsequent to stillbirth: Medical and psychosocial aspects of care.

Semin Fetal Neonatal Med 2017 06 3;22(3):186-192. Epub 2017 Mar 3.

Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada; Maternal Fetal Medicine, Sunnybrook Health Science Centre, Toronto, Ontario, Canada; Clinical Trials Services/The Centre for Mother, Infant and Child Research, Toronto, Ontario, Canada.

Pregnancy after stillbirth presents unique challenges for families and healthcare providers. Medical surveillance and interventions must be optimized to improve outcomes and provide individualized support for families. A key component of acceptable care is psychosocial support that is delivered in a timely and sensitive manner by care providers with knowledge about the pervasive impact of stillbirth. With the lack of existing evidence to guide care, there is an urgent need for global leadership and research to address knowledge gaps.
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http://dx.doi.org/10.1016/j.siny.2017.02.004DOI Listing
June 2017

Atonic Postpartum Hemorrhage: Blood Loss, Risk Factors, and Third Stage Management.

J Obstet Gynaecol Can 2016 12 17;38(12):1081-1090.e2. Epub 2016 Aug 17.

Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver BC; School of Population and Public Health, University of British Columbia, Vancouver BC.

Objective: Atonic postpartum hemorrhage rates have increased in many industrialized countries in recent years. We examined the blood loss, risk factors, and management of the third stage of labour associated with atonic postpartum hemorrhage.

Methods: We carried out a case-control study of patients in eight tertiary care hospitals in Canada between January 2011 and December 2013. Cases were defined as women with a diagnosis of atonic postpartum hemorrhage, and controls (without postpartum hemorrhage) were matched with cases by hospital and date of delivery. Estimated blood loss, risk factors, and management of the third stage labour were compared between cases and controls. Conditional logistic regression was used to adjust for confounding.

Results: The study included 383 cases and 383 controls. Cases had significantly higher mean estimated blood loss than controls. However, 16.7% of cases who delivered vaginally and 34.1% of cases who delivered by Caesarean section (CS) had a blood loss of < 500 mL and < 1000 mL, respectively; 8.2% of controls who delivered vaginally and 6.7% of controls who delivered by CS had blood loss consistent with a diagnosis of postpartum hemorrhage. Factors associated with atonic postpartum hemorrhage included known protective factors (e.g., delivery by CS) and risk factors (e.g., nulliparity, vaginal birth after CS). Uterotonic use was more common in cases than in controls (97.6% vs. 92.9%, P < 0.001). Delayed cord clamping was only used among those who delivered vaginally (7.7% cases vs. 14.6% controls, P = 0.06).

Conclusion: There is substantial misclassification in the diagnosis of atonic postpartum hemorrhage, and this could potentially explain the observed temporal increase in postpartum hemorrhage rates.
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http://dx.doi.org/10.1016/j.jogc.2016.06.014DOI Listing
December 2016

Progesterone supplementation for HIV-positive pregnant women on protease inhibitor-based antiretroviral regimens (the ProSPAR study): a study protocol for a pilot randomized controlled trial.

Pilot Feasibility Stud 2016 12;2:49. Epub 2016 Aug 12.

Toronto General Research Institute, Toronto, Canada ; University of Toronto, Toronto, Canada ; Women's College Research Institute, Toronto, Canada.

Background: In Canada, the majority of HIV-positive pregnant women receive combination antiretroviral therapy that includes a ritonavir-boosted protease inhibitor to prevent mother-to-child HIV transmission. However, protease inhibitor-based combination antiretroviral therapy has been associated with increased rates of preterm, low birth weight, and small for gestational age births. Our previous experimental findings demonstrate that protease inhibitor use during pregnancy is associated with decreased progesterone levels that correlate with fetal growth, and that progesterone supplementation can improve protease inhibitor-induced fetal growth restriction. We hypothesize that HIV-positive pregnant women who receive protease inhibitor-based combination therapy may also benefit from progesterone supplementation during pregnancy.

Methods/design: In order to test this hypothesis, we have designed an open-label, multi-centre, randomized controlled (parallel group) pilot trial. The initial goal of this trial is to test feasibility and acceptability of our intervention. Forty HIV-positive pregnant women who are either on, or intending to start or switch to a boosted protease inhibitor-based combination antiretroviral regimen will be enrolled from six sites across Ontario, Canada. Twenty-five women will be randomized to self-administer natural progesterone (Prometrium, 200 mg) vaginally every night starting between gestational week 16 and 24 until week 36, and 15 women will be randomized to no intervention. While the participants and treating physicians will not be blinded, the laboratory personnel performing the biochemical and morphological evaluations will be blinded to ensure unbiased evaluation. The primary outcome of the pilot study is the feasibility of enrolment as measured by the recruitment rate and patient-reported reasons to decline participation. Secondary outcomes in participants include safety, acceptability, and adherence to progesterone supplementation.

Discussion: Given the safety of intravaginal progesterone and its current use in the general obstetrical population to prevent recurrent preterm delivery, this pilot study will provide data to determine the feasibility of a larger randomized controlled trial to assess the impact of this intervention on improving neonatal health in the context of HIV-positive pregnancies.

Trial Registration: ClinicalTrials.gov, NCT02400021.
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http://dx.doi.org/10.1186/s40814-016-0087-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5153916PMC
August 2016

Dyssegmental dysplasia, Silverman-Handmaker type: prenatal ultrasound findings and molecular analysis.

Prenat Diagn 2013 Nov 4;33(11):1039-43. Epub 2013 Aug 4.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.

Objectives: The objective of this study is to describe the prenatal sonographic features and the results of DNA analysis on three fetuses with dyssegmental dysplasia, Silverman-Handmaker type (DD-SH).

Methods: A retrospective review of three fetuses with confirmed DD-SH was conducted. The fetal ultrasound findings, the radiological characteristics, and the results of the mutation analysis of the heparan sulphate perlecan gene 2 (HSPG2) were reviewed.

Results: There were three cases in two families with DD-SH diagnosed prenatally. The main prenatal ultrasound and the radiological features of DD-SH were severe limb shortening and vertebral segmentation and fusion defects (anisospondyly). The DNA analysis of the HSPG2 gene showed that the two affected fetuses in a nonconsanguineous family had a compound heterozygote for the c.646G > T transversion in exon 7 and a c.5788C > T transition in exon 46. The fetus born to the consanguineous couple had a homozygous mutation c.1356-27_1507 + 59del.

Conclusion: DD-SH can be diagnosed prenatally using fetal ultrasound as early as 13 weeks. Xrays and DNA analysis of the HSPG2 gene are important for the confirmation of the diagnosis and for the preimplantation and prenatal diagnosis in pregnancies at risk.
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http://dx.doi.org/10.1002/pd.4193DOI Listing
November 2013

Prenatal amphetamine exposure and birth outcomes: a systematic review and metaanalysis.

Am J Obstet Gynecol 2011 Sep 16;205(3):219.e1-7. Epub 2011 Apr 16.

Department of Obstetrics and Gynecology, University of Toronto Faculty of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada.

Objective: The aim of this study was to systematically review the relationship between amphetamine exposure in pregnancy and birth outcomes.

Study Design: Electronic databases were searched to identify relevant studies. Data from included studies were extracted by 2 reviewers. Summary odds ratio (OR) and confidence intervals (CIs) were calculated using the random effects model.

Results: Ten studies were included. Significant increases in unadjusted risks of preterm birth (OR, 4.11; 95% CI, 3.05-5.55), low birthweight (OR, 3.97; 95% CI, 2.45-6.43), and small for gestational age (OR, 5.79; 95% CI, 1.39-24.06) were identified among women exposed to amphetamines in pregnancy. The mean birthweight was significantly lower among amphetamine-exposed pregnancies (mean difference, -279 g; 95% CI, -485 to -74 g). Two studies provided adjusted estimates on different outcomes, and their results were consistent with the findings from the unadjusted data.

Conclusion: Amphetamine exposure in pregnancy is associated with adverse birth outcomes and should be identified by physicians providing antenatal care.
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http://dx.doi.org/10.1016/j.ajog.2011.04.016DOI Listing
September 2011

Treatment variability and outcome differences in the emergency department management of alcohol withdrawal.

CJEM 2005 Mar;7(2):87-92

Addiction Medicine Service, St. Joseph's Health Centre, Toronto, Ontario, Canada.

Objective: Evidence suggests that symptom-triggered benzodiazepine treatment for patients with alcohol withdrawal reduces complication rates and emergency department lengths of stay. Our objective was to describe the management of alcohol withdrawal in 2 urban emergency departments.

Methods: A structured chart audit was performed for patients with alcohol-related problems who presented to 2 Toronto hospitals over a 2-year period.

Results: A total of 209 emergency department charts were audited. Patient characteristics were similar in both hospitals. None of the patients had been assessed using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Patients at one hospital received substantially higher mean diazepam doses (64 mg v. 26 mg; p < 0.001) than did the patients at the other hospital, and the patients at the first hospital had fewer seizures during their emergency department stay (1% v. 9%; p = 0.012). Patients spent an average of 9 hours and 40 minutes in the emergency department.

Conclusion: There is significant variability in the documentation and treatment of alcohol withdrawal. Lower benzodiazepine doses are associated with higher rate of withdrawal seizures and prolonged emergency department length of stay. A standardized approach using symptom-triggered management is likely to improve outcomes for patients presenting with alcohol withdrawal.
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http://dx.doi.org/10.1017/s1481803500013038DOI Listing
March 2005