Obesity in Pregnancy Davies, Gregory A.L., MD; Maxwell, Cynthia, MD; McLeod, Lynne, MD ...
Journal of obstetrics and gynaecology Canada,
02/2010, Letnik:
32, Številka:
2
Journal Article
Recenzirano
Abstract Objective To review the evidence and provide recommendations for the counselling and management of obese parturients. Outcomes Outcomes evaluated include the impact of maternal obesity on ...the provision of antenatal and intrapartum care, maternal morbidity and mortality, and perinatal morbidity and mortality. Evidence Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to April 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice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 obtained was reviewed and evaluated by the Maternal Fetal Medicine and Clinical Practice Obstetric Committees of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Benefits, Harms, and Costs: Implementation of the recommendations in this guideline should increase recognition of the issues clinicians need to be aware of when managing obese women in pregnancy, improve communication and consultation amongst the obstetrical care team, and encourage federal and provincial agencies to educate Canadians about the values of entering pregnancy with as healthy a weight as possible. Recommendations 1. Periodic health examinations and other appointments for gynaecologic care prior to pregnancy offer ideal opportunities to raise the issue of weight loss before conception. Women should be encouraged to enter pregnancy with a BMI < 30 kg/m2 , and ideally < 25 kg/m2 . (III-B) 2. BMI should be calculated from pre-pregnancy height and weight. Those with a pre-pregnancy BMI > 30 kg/m2 are considered obese. This information can be helpful in counselling women about pregnancy risks associated with obesity. (II-2B) 3. Obese pregnant women should receive counselling about weight gain, nutrition, and food choices. (II-2B) 4. Obese women should be advised that they are at risk for medical complications such as cardiac disease, pulmonary disease, gestational hypertension, gestational diabetes, and obstructive sleep apnea. Regular exercise during pregnancy may help to reduce some of these risks. (II-2B) 5. Obese women should be advised that their fetus is at an increased risk of congenital abnormalities, and appropriate screening should be done. (II-2B) 6. Obstetric care providers should take BMI into consideration when arranging for fetal anatomic assessment in the second trimester. Anatomic assessment at 20 to 22 weeks may be a better choice for the obese pregnant patient. (II-2B) 7. Obese pregnant women have an increased risk of Caesarean section, and the success of vaginal birth after Caesarean section is decreased. (II-2B) 8. Antenatal consultation with an anaesthesiologist should be considered to review analgesic options and to ensure a plan is in place should a regional anaesthetic be chosen. (III-B) 9. The risk of venous thromboembolism for each obese woman should be evaluated. In some clinical situations, consideration for thromboprophylaxis should be individualized. (III-B)
Magnesium Sulphate for Fetal Neuroprotection Magee, Laura, MD; Sawchuck, Diane, RN, PhD; Synnes, Anne, MD ...
Journal of obstetrics and gynaecology Canada,
05/2011, Letnik:
33, Številka:
5
Journal Article
Recenzirano
Abstract Objective To provide guidelines for the use of antenatal magnesium sulphate (MgSO4 ) for fetal neuroprotection of the preterm infant. Options Antenatal MgSO4 administration should be ...considered for fetal neuroprotection when women present at ≤ 31+6 weeks with imminent preterm birth, defined as a high likelihood of birth because of active labour with cervical dilatation ≥ 4 cm, with or without preterm pre-labour rupture of membranes, and/or planned preterm birth for fetal or maternal indications. There are no other known fetal neuroprotective agents. Outcomes The outcomes measured are the incidence of cerebral palsy (CP) and neonatal death. Evidence Published literature was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library in May 2010, using appropriate controlled vocabulary and key words (magnesium sulphate, cerebral palsy, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, and relevant observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to August 2010. 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 quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Benefits, harms, and costs: Antenatal magnesium sulphate for fetal neuroprotection reduces the risk of “death or CP” (RR 0.85; 95% CI 0.74 to 0.98; 4 trials, 4446 infants), “death or moderatesevere CP” (RR 0.85; 95% CI 0.73 to 0.99; 3 trials, 4250 infants), “any CP” (RR 0.71; 95% CI 0.55 to 0.91; 4, trials, 4446 infants), “moderate-to-severe CP” (RR 0.60; 95% CI 0.43 to 0.84; 3 trials, 4250 infants), and “substantial gross motor dysfunction” (inability to walk without assistance) (RR 0.60; 95% CI 0.43 to 0.83; 3 trials, 4287 women) at 2 years of age. Results were consistent between trials and across the meta-analyses. There is no anticipated significant increase in health care-related costs, because women eligible to receive antenatal MgSO4 will be judged to have imminent preterm birth. Validation Australian National Clinical Practice Guidelines were published in March 2010 by the Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel. Antenatal MgSO4 was recommended for fetal neuroprotection in the same dosage as recommended in these guidelines. However, MgSO4 was recommended only at < 30 weeks’ gestation, based on 2 considerations. First, no one gestational age subgroup was considered to show a clear benefit. Second, in the face of uncertainty, the committee felt it was prudent to limit the impact of their clinical practice guidelines on resource allocation. Also in March 2010, the American College of Obstetricians and Gynecologists issued a Committee Opinion on MgSO4 for fetal neuroprotection. It stated that, “the available evidence suggests that magnesium sulphate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants.” No official opinion was given on a gestational age cut-off, but it was recommended that physicians develop specific guidelines around the issues of inclusion criteria, dosage, concurrent tocolysis, and monitoring in accordance with one of the larger trials. Sponsors Canadian Institutes of Health Research (CIHR).
Ultrasound in Twin Pregnancies Morin, Lucie, MD; Lim, Kenneth, MD; Bly, Stephen, MD ...
Journal of obstetrics and gynaecology Canada,
06/2011, Letnik:
33, Številka:
6
Journal Article
Recenzirano
Abstract Objective To review the literature with respect to the use of diagnostic ultrasound in the management of twin pregnancies. To make recommendations for the best use of ultrasound in twin ...pregnancies Outcomes Reduction in perinatal mortality and morbidity and short- and long-term neonatal morbidity in twin pregnancies. Optimization of ultrasound use in twin pregnancies. Evidence Published literature was retrieved through searches of PubMed and the Cochrane Library in 2008 and 2009 using appropriate controlled vocabulary (e. g., twin, ultrasound, cervix, prematurity) and key words (e. g., acardiac, twin, reversed arterial perfusion, twin-to-twin transfusion syndrome, amniotic fluid). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions. Studies were restricted to those with available English or French abstracts or text. Searches were updated on a regular basis and incorporated into the guideline to September 2009. 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 collected was reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada, with input from members of the Maternal Fetal Medicine Committee and the Genetics Committee of the SOGC. The recommendations were made according to the guidelines developed by The Canadian Task Force on Preventive Health Care (Table 1). Benefits, harms, and costs The benefit expected from this guideline is facilitation and optimization of the use of ultrasound in twin pregnancy.
Substance Use in Pregnancy Wong, Suzanne, MD; Ordean, Alice, MD; Kahan, Meldon, MD ...
Journal of obstetrics and gynaecology Canada,
04/2011, Letnik:
33, Številka:
4
Journal Article
Recenzirano
Abstract Objective To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for ...all health care providers Options This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy. Outcomes Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation. Evidence Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also 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 quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care Recommendations for practice were ranked according to the method described in that report (Table 1) Benefits, harms, and costs This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality. Recommendations 1. All pregnant women and women of childbearing age should be screened periodically for alcohol, tobacco, and prescription and illicit drug use. (III-A) 2. When testing for substance use is clinically indicated, urine drug screening is the preferred method. (II-2A) Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered. (III-B) 3. Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region. (III-A) 4. Health care providers should employ a flexible approach to the care of women who have substance use problems, and they should encourage the use of all available community resources. (II-2B) 5. Women should be counselled about the risks of periconception, antepartum, and postpartum drug use. (III-B) 6. Smoking cessation counselling should be considered as a first-line intervention for pregnant smokers. (I-A) Nicotine replacement therapy and/or pharmacotherapy can be considered if counselling is not successful. (I-A) 7. Methadone maintenance treatment should be standard of care for opioid-dependent women during pregnancy. (II-IA) Other slow-release opioid preparations may be considered if methadone is not available. (II-2B) 8. Opioid detoxification should be reserved for selected women because of the high risk of relapse to opioids. (II-2B) 9. Opiate-dependent women should be informed that neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome). (II-2B) Hospitals providing obstetric care should develop a protocol for assessment and management of neonates exposed to opiates during pregnancy. (III-B) 10. Antenatal planning for intrapartum and postpartum analgesia may be offered for all women in consultation with appropriate health care providers. (III-B) 11. The risks and benefits of breastfeeding should be weighed on an individual basis because methadone maintenance therapy is not a contraindication to breastfeeding. (II-3B)
Abstract 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
Accouchement du siège par voie vaginale Kotaska, Andrew, MD; Menticoglou, Savas, MD; Gagnon, Robert, MD ...
Journal of obstetrics and gynaecology Canada,
2009, Letnik:
31, Številka:
6
Journal Article
Recenzirano
Résumé Objectifs Analyser la physiologie de l’accouchement du siège, discerner les risques et les avantages d’un essai de travail, par comparaison avec la césarienne planifiée, ainsi que recommander ...(aux obstétriciens, aux médecins de famille, aux sages-femmes, aux infirmières obstétricales, aux anesthésiologistes, aux pédiatres et aux autres fournisseurs de soins de santé) des critères de sélection, des paramètres de prise en charge intrapartum et des techniques d’accouchement pour un essai d’accouchement du siège par voie vaginale. Options L’essai de travail dans un milieu approprié ou l’accouchement par césarienne préventive pour les femmes dont la grossesse monofoetale est en présentation du siège à terme. Issues Baisse de la mortalité périnatale, de la morbidité néonatale à court terme, de la morbidité infantile à long terme et de la morbidité et de la mortalité maternelles à court et à long terme. Résultats Des recherches ont été menées dans Medline en vue d’en tirer les essais randomisés, les études de cohorte prospectives et certaines études de cohorte rétrospectives comparant la césarienne planifiée et l’essai de travail planifié; certaines études épidémiologiques comparant la césarienne et l’accouchement du siège par voie vaginale; et les études comparant les issues à long terme chez les enfants en présentation du siège nés par voie vaginale ou par césarienne. Des articles supplémentaires ont été identifiés par l’intermédiaire de la bibliographie (allant jusqu’au 1er juin 2008). Valeurs Les résultats obtenus ont été analysés par le comité de médecine foeto-maternelle de la Société des obstétriciens et gynécologues du Canada (SOGC) et quantifiés au moyen des critères et des classifications du Groupe d’étude canadien sur les soins de santé préventifs. Validation La présente directive clinique a été comparée à l’opinion de comité 2006 du American College of Obstetrician sur le mode d’accouchement du siège d’une grossesse monofoetale et de la directive clinique Green Top : The Management of Breech Presentation 2006 du Royal College of Obstetrician and Gynaecologists . Le document a été analysé par des cliniciens canadiens et internationaux disposant d’une expertise particulière en matière d’accouchement du siège par voie vaginale. Commanditaire La Société des obstétriciens et gynécologues du Canada. Déclarations sommaires 1. L’accouchement du siège par voie vaginale peut être associé à un risque de mortalité périnatale et de morbidité néonatale à court terme plus élevé que celui qui est associé à la césarienne de convenance. (I) 2. La sélection des cas et la prise en charge du travail de façon rigoureuse au sein d’un milieu obstétrical moderne peut permettre l’obtention d’un degré de sûreté semblable à celui de la césarienne de convenance. (II-1) 3. L’accouchement vaginal planifié est raisonnable chez certaines femmes dont la grossesse monofoetale est en présentation du siège à terme. (I) 4. En présence d’une sélection des cas et d’une prise en charge du travail de façon rigoureuse, la mortalité périnatale survient dans environ deux naissances sur 1 000; une morbidité néonatale grave à court terme est alors constatée chez environ 2 % des enfants en présentation du siège. De nombreux signalements récents d’études rétrospectives et prospectives portant sur l’accouchement du siège par voie vaginale en fonction de protocoles particuliers ont indiqué d’excellentes issues néonatales. (II-1) 5. Les issues neurologiques infantiles à long terme ne diffèrent pas en fonction du mode d’accouchement planifié, même en présence d’une grave morbidité néonatale à court terme. (I) Recommandations Critères de sélection du travail 1. Dans le cas d’une femme chez laquelle l’on soupçonne une présentation du siège, une échographie prétravail ou aux débuts du travail devrait être menée pour évaluer le type de présentation du siège en question, la croissance foetale et le poids estimatif, ainsi que l’attitude de la tête foetale. Lorsque l’échographie n’est pas disponible, la césarienne est recommandée. (II-1A) 2. Parmi les contre-indications au travail, on trouve ce qui suit : a. Présentation du cordon. (II-3A) b. Retard de croissance intra-utérin ou macrosomie. (I-A) c. Toute présentation autre qu’un siège décomplété ou un siège complet, accompagnée d’une attitude fléchie ou neutre de la tête foetale. (III-B) d. Bassin maternel inadéquat sur le plan clinique. (III-B) e. Anomalie foetale n’étant pas compatible avec l’accouchement vaginal. (III-B) 3. L’accouchement du siège par voie vaginale peut être offert lorsque le poids foetal estimatif se situe entre 2 500 g et 4 000 g. (II-2B) Prise en charge du travail 4. Un examen pelvien clinique devrait être effectué pour écarter la présence possible d’une contraction pelvienne pathologique. La tenue d’une pelvimétrie radiologique n’est pas nécessaire pour assurer la sûreté d’un essai de travail; un travail qui connaît une bonne évolution constitue le meilleur indicateur de proportions foeto-pelviennes adéquates. (III-B) 5. Le monitorage électronique continu de la fréquence cardiaque foetale est préférable au cours du premier stade du travail et obligatoire au cours du deuxième. (I-A) Lorsque les membranes se rompent, la tenue immédiate d’un examen vaginal est recommandée pour écarter la présence possible d’une procidence du cordon. (III-B) 6. En l’absence d’une évolution adéquate du travail, la tenue d’une césarienne est conseillée. (II-1A) 7. Le déclenchement du travail n’est pas recommandé lorsque le foetus est en présentation du siège. (II-3B) L’accélération à l’oxytocine est acceptable en présence d’une dystocie utérine. (II-1A) 8. Un deuxième stade passif sans poussée active peut durer jusqu’à 90 minutes, ce qui permet au siège de bien s’engager dans le bassin. Lorsque la poussée active débute, si l’accouchement n’est pas imminent après 60 minutes, la tenue d’une césarienne est recommandée. (I-A) 9. Le deuxième stade actif du travail devrait se dérouler au sein d’une salle d’opération ou près d’une telle salle dotée de matériel et de personnel permettant l’exécution d’une césarienne en temps opportun, au besoin. (III-A) 10. Un professionnel de la santé expérimenté en matière de réanimation néonatale devrait être présent au moment de l’accouchement. (III-A) Technique d’accouchement 11. Dans le cadre d’un accouchement du siège par voie vaginale planifié, le fournisseur de soins de santé se doit de compter l’expérience et les compétences requises. (II-1A) 12. Un obstétricien-gynécologue expérimenté, rompu à la tenue d’accouchements du siège par voie vaginale, devrait être présent au moment de l’accouchement afin de superviser le travail des autres fournisseurs de soins de santé, y compris un stagiaire. (I-A) 13. Les exigences relatives à la tenue d’une césarienne d’urgence (y compris la disponibilité de l’équipe opératoire de l’hôpital et le délai approximatif de 30 minutes nécessaire à la mise en oeuvre d’une laparotomie) doivent être conformes aux recommandations de la déclaration de principe de la SOGC suivante : « La présence du personnel médical au moment du travail et de l’accouchement Lignes directrices sur les soins obstétricaux » (Directive clinique de la SOGC n° 89; mise à jour sous presse, 2009). (III-A) 14. Le fournisseur de soins de santé devrait disposer d’un plan d’action ayant fait l’objet de répétitions et devrait être en mesure d’agir rapidement dans les rares cas de tête dernière coincée ou de bras indélogeables : une symphyséotomie ou un sauvetage d’urgence par voie abdominale peuvent permettre d’éviter le décès. (III-B) 15. L’extraction totale du siège est inappropriée dans le cadre de l’accouchement d’une grossesse monofoetale en présentation du siège à terme. (II-2A) 16. Des efforts de poussée maternelle efficaces sont essentiels à la tenue de l’accouchement en toute sûreté et devrait être encouragés. (II-1A) 17. Au moment de l’accouchement de la tête dernière, un adjoint devrait être présent pour appliquer une pression suspubienne visant à favoriser la flexion et l’engagement de la tête foetale. (II-3B) 18. L’accouchement du siège spontané ou assisté est acceptable. La traction foetale devrait être évitée; la manipulation foetale ne doit être mise en oeuvre qu’à la suite de l’accouchement spontané jusqu’au niveau de l’ombilic. (III-A) 19. Les bras coincés derrière la tête peuvent être délogés au moyen des manoeuvres de Løvset ou de Bickenbach. (III-B) 20. La tête foetale peut être accouchée de façon spontanée, avec l’aide d’une pression suspubienne, au moyen de la manoeuvre de Mauriceau-Smellie-Veit ou avec l’aide de forceps de Piper. (III-B) Milieu et consentement 21. En l’absence d’une contre-indication à l’accouchement vaginal, la patiente dont la grossesse est en présentation du siège devrait être avisée des risques et des avantages d’un essai de travail et d’une césarienne de convenance; de plus, son consentement éclairé devrait être obtenu. Le choix de la patiente quant au mode d’accouchement devrait être respecté. (III-A) 22. La discussion quant au consentement et le plan choisi devraient être bien documentés et communiqués au personnel de la salle de travail. (III-B) 23. Les hôpitaux offrant un essai de travail devraient disposer d’un protocole écrit en ce qui concerne l’admissibilité et la prise en charge intrapartum. (III-B) 24. Les femmes qui présentent une contre-indication à l’essai de travail devraient se voir conseiller de subir une césarienne. Les femmes qui choisissent un essai de travail malgré cette recommandation ont le droit d’agir de la sorte et ne devraient pas être abandonnées. Elles devraient bénéficier des meilleurs soins hospitaliers possibles. (III-A) 25. La Société des obstétriciens et gynécologues du Canada (SOGC), en collaboration avec l’Association des professeurs d’obstétrique et gynécologie (APOG), le Collège des médecins de famille du Canada (CMFC) et l’Association canadienne des sages-femmes (ACSF), devrait réviser les exi
Abstract Objective To review the evidence and provide recommendations on the use of antibiotics in preterm premature rupture of the membranes (PPROM). Outcomes Outcomes evaluated include the effect ...of antibiotic treatment on maternal infection, chorioamnionitis, and neonatal morbidity and mortality. Evidence Published literature was retrieved through searches of Medline, EMBASE, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary and key words (PPROM, infection, and antibiotics). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and new material incorporated in the guideline to July 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 national and international medical specialty societies. Values The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Benefits, Harms, and Costs Guideline implementation should assist the practitioner in developing an approach to the use of antibiotics in women with PPROM. Patients will benefit from appropriate management of this condition. Validation This guideline has been reviewed and approved by the Infectious Diseases Committee and the Maternal Fetal Medicine Committee of the SOGC, and approved by the Executive and Council of the SOGC. Sponsor The Society of Obstetricians and Gynaecologists of Canada.
Vaginal Delivery of Breech Presentation Kotaska, Andrew, MD; Menticoglou, Savas, MD; Gagnon, Robert, MD ...
Journal of obstetrics and gynaecology Canada
31, Številka:
6
Journal Article
Recenzirano
Abstract Objectives To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family ...physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth. Options Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean section for women with a singleton breech fetus at term. Outcomes Reduced perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short- and long-term maternal morbidity and mortality. Evidence Medline was searched for randomized trials, prospective cohort studies, and selected retrospective cohort studies comparing planned Caesarean section with a planned trial of labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean section. Additional articles were identified through bibliography tracing up to June 1, 2008. Values The evidence collected was reviewed by the Maternal Fetal Medicine Committee 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. Validation This guideline was compared with the 2006 American College of Obstetrician’s Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery. Sponsors The Society of Obstetricians and Gynaecologists of Canada. Summary Statements 1. Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term neonatal morbidity than elective Caesarean section. (I) 2. Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to elective Caesarean section. (II-1) 3. Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus. (I) 4. With careful case selection and labour management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. Many recent retrospective and prospective reports of vaginal breech delivery that follow specific protocols have noted excellent neonatal outcomes. (II-1) 5. Long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity. (I) Recommendations Labour Selection Criteria 1. For a woman with suspected breech presentation, pre- or early labour ultrasound should be performed to assess type of breech presentation, fetal growth and estimated weight, and attitude of fetal head. If ultrasound is not available, Caesarean section is recommended. (II-1A) 2. Contraindications to labour include a. Cord presentation (II-3A) b. Fetal growth restriction or macrosomia (I-A) c. Any presentation other than a frank or complete breech with a flexed or neutral head attitude (III-B) d. Clinically inadequate maternal pelvis (III-B) e. Fetal anomaly incompatible with vaginal delivery (III-B) 3. Vaginal breech delivery can be offered when the estimated fetal weight is between 2500 g and 4000 g. (II-2B) Labour Management 4. Clinical pelvic examination should be performed to rule out pathological pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial of labour; good progress in labour is the best indicator of adequate fetal-pelvic proportions. (III-B) 5. Continuous electronic fetal heart monitoring is preferable in the first stage and mandatory in the second stage of labour. (I-A) When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord. (III-B) 6. In the absence of adequate progress in labour, Caesarean section is advised. (II-1A) 7. Induction of labour is not recommended for breech presentation. (II-3B) Oxytocin augmentation is acceptable in the presence of uterine dystocia. (II-1A) 8. A passive second stage without active pushing may last up to 90 minutes, allowing the breech to descend well into the pelvis. Once active pushing commences, if delivery is not imminent after 60 minutes, Caesarean section is recommended. (I-A) 9. The active second stage of labour should take place in or near an operating room with equipment and personnel available to perform a timely Caesarean section if necessary. (III-A) 10. A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery. (III-A) Delivery Technique 11. The health care provider for a planned vaginal breech delivery needs to possess the requisite skills and experience. (II-1A) 12. An experienced obstetrician-gynaecologist comfortable in the performance of vaginal breech delivery should be present at the delivery to supervise other health care providers, including a trainee. (I-A) 13. The requirements for emergency Caesarean section, including availability of the hospital operating room team and the approximate 30-minute timeline to commence a laparotomy, must be in accordance with the recommendations of the SOGC Policy Statement, “Attendance at Labour and Delivery” (CPG No. 89; update in press, 2009). (III-A) 14. The health care provider should have rehearsed a plan of action and should be prepared to act promptly in the rare circumstance of a trapped after-coming head or irreducible nuchal arms: symphysiotomy or emergency abdominal rescue can be life saving. (III-B) 15. Total breech extraction is inappropriate for term singleton breech delivery. (II-2A) 16. Effective maternal pushing efforts are essential to safe delivery and should be encouraged. (II-1A) 17. At the time of delivery of the after-coming head, an assistant should be present to apply suprapubic pressure to favour flexion and engagement of the fetal head. (II-3B) 18. Spontaneous or assisted breech delivery is acceptable. Fetal traction should be avoided, and fetal manipulation must be applied only after spontaneous delivery to the level of the umbilicus. (III-A) 19. Nuchal arms may be reduced by the Løvset or Bickenbach manoeuvres. (III-B) 20. The fetal head may deliver spontaneously, with the assistance of suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or with the assistance of Piper forceps. (III-B) Setting and Consent 21. In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a trial of labour and elective Caesarean section, and informed consent should be obtained. A woman’s choice of delivery mode should be respected. (III-A) 22. The consent discussion and chosen plan should be well documented and communicated to labour-room staff. (III-B) 23. Hospitals offering a trial of labour should have a written protocol for eligibility and intrapartum management. (III-B) 24. Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care. (III-A) 25. The Society of Obstetricians and Gynaecologists of Canada (SOGC), in collaboration with the Association of Professors of Obstetrics and Gynaecology (APOG), The College of Family Physicians of Canada (CFPC), and The Canadian Association of Midwives (CAM) should revise the training requirements at the undergraduate and postgraduate levels. SOGC will continue to promote training of current health care providers through the MOREOB , ALARM (Advances in Labour and Risk Management), and other courses. (III-A) 26. Theoretical and hands-on breech birth training simulation should be part of basic obstetrical skills training programs such as ALARM, ALSO (Advanced Life Support Training in Obstetrics), and MOREOB to prepare health care providers for unexpected vaginal breech births. (III-B)
Abstract Objective To advocate for the use of a common classification system for Caesarean section across Canada. Options A variety of clinical parameters for classification were considered. Outcomes ...Consideration of a common system for classifying Caesarean section. Evidence Studies published in English from 1976 to December 2011 were retrieved through searches of Medline and PubMed, using appropriate controlled vocabulary and key words (Caesarean section, vaginal birth after Caesarean, classification). Resultswere restricted to systematic reviews, randomized controltrials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified through searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and the web sites of national and international medical specialty societies. Values The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendation for practice ranked according to this classification (Table 1). Sponsors The Society of Obstetricians and Gynaecologists of Canada. Recommendation Modified Robson criteria should be used to enable comparison of Caesarean section rates and indications. (III-B)
Cytomegalovirus Infection in Pregnancy Yinon, Yoav, MD; Farine, Dan, MD; Yudin, Mark H., MD ...
Journal of obstetrics and gynaecology Canada,
04/2010, Letnik:
32, Številka:
4
Journal Article
Recenzirano
Abstract Objectives To review the principles of prenatal diagnosis of congenital cytomegalovirus (CMV) infection and to describe the outcomes of the affected pregnancies. Outcomes Effective ...management of fetal infection following primary and secondary maternal CMV infection during pregnancy. Neonatal signs include intrauterine growth restriction (IUGR), microcephaly, hepatosplenomegaly, petechiae, jaundice, chorioretinitis, thrombocytopenia and anemia, and long-term sequelae consist of sensorineural hearing loss, mental retardation, delay of psychomotor development, and visual impairment. These guidelines provide a framework for diagnosis and management of suspected CMV infections. Evidence Medline was searched for articles published in English from 1966 to 2009, using appropriate controlled vocabulary (congenital CMV infection) and key words (intrauterine growth restriction, microcephaly). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated into the guideline. 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. Recommendations The quality of evidence reported in this document has been assessed using the evaluation of evidence criteria in the Report of the Canadian Task Force on Preventive Health Care (Table 1). 1. Diagnosis of primary maternal cytomegalovirus (CMV) infection in pregnancy should be based on de-novo appearance of virus-specific IgG in the serum of a pregnant woman who was previously seronegative, or on detection of specific IgM antibody associated with low IgG avidity. (II-2A) 2. In case of primary maternal infection, parents should be informed about a 30% to 40% risk for intrauterine transmission and fetal infection, and a risk of 20% to 25% for development of sequelae postnatally if the fetus is infected. (II-2A) 3. The prenatal diagnosis of fetal CMV infection should be based on amniocentesis, which should be done at least 7 weeks after presumed time of maternal infection and after 21 weeks of gestation. This interval is important because it takes 5 to 7 weeks following fetal infection and subsequent replication of the virus in the kidney for a detectable quantity of the virus to be secreted to the amniotic fluid. (II-2A) 4. The diagnosis of secondary infection should be based on a significant rise of IgG antibody titre with or without the presence of IgM and high IgG avidity. In cases of proven secondary infection, amniocentesis may be considered, but the risk–benefit ratio is different because of the low transmission rate. (III-C) 5. Following a diagnosis of fetal CMV infection, serial ultrasound examinations should be performed every 2 to 4 weeks to detect sonographic abnormalities, which may aid in determining the prognosis of the fetus, although it is important to be aware that the absence of sonographic findings does not guarantee a normal outcome. (II-2B) 6. Quantitative determination of CMV DNA in the amniotic fluid may assist in predicting the fetal outcome. (II-3B) 7. Routine screening of pregnant women for CMV by serology testing is currently not recommended. (III-B) 8. Serologic testing for CMV may be considered for women who develop influenza-like illness during pregnancy or following detection of sonographic findings suggestive of CMV infection. (III-B) 9. Seronegative health care and child care workers may be offered serologic monitoring during pregnancy. Monitoring may also be considered for seronegative pregnant women who have a young child in day care. (III-B)
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