Guideline No. 430: Diagnosis and management of preterm prelabour rupture of membranes.

OBJECTIVE: To provide clear and concise guidelines for the diagnosis and management of preterm prelabour rupture of membranes (PPROM) TARGET POPULATION: All patients with PPROM <37 weeks gestation BENEFITS, HARMS, AND COSTS: This guideline aims to provide the first Canadian general guideline on the management of preterm membrane rupture. It includes a comprehensive and up-to-date review of the evidence on the diagnosis, management, timing and method of delivery. EVIDENCE: The following search terms were entered into PubMed/Medline and Cochrane in 2021: preterm premature rupture of membranes, PPROM, chorioamnionitis, Nitrazine test, ferning, commercial tests, placental alpha microglobulin-1 (PAMG-1) test, insulin-like growth factor-binding protein-1 (IGFBP-1) test, ultrasonography, PPROM/antenatal corticosteroids, PPROM/Magnesium sulphate, PPROM/ antibiotic treatment, PPROM/tocolysis, PPROM/preterm labour, PPROM/Neonatal outcomes, PPROM/mortality, PPROM/outpatient/inpatient, PPROM/cerclage, previable PPROM. Articles included were randomized controlled trials, meta-analyses, systematic reviews, guidelines, and observational studies. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: All prenatal and perinatal health care providers. SUMMARY STATEMENTS: RECOMMENDATIONS.

Directive clinique no 430: diagnostic et prise en charge de la rupture prématurée des membranes avant terme / Guideline No. 430: Diagnosis and Management of Preterm Premature Rupture of Membranes

Fournir des directives claires et concises pour le diagnostic et la prise en charge de la rupture prématurée des membranes avant terme (RPMAT). Population cible Toute patiente manifestant une rupture prématurée des membranes avant 37 semaines d'aménorrhée. Bénéfices, risques et coûts La présente directive clinique vise à fournir les premières recommandations générales canadiennes sur la prise en charge de la rupture des membranes avant terme. Elle repose sur un examen complet et à jour des données probantes sur le diagnostic de la rupture et sur la prise en charge, le bon moment et les modes d'accouchement. Données probantes Des recherches ont été effectuées dans PubMed-Medline et Cochrane en 2021 en utilisant les termes suivants : preterm premature rupture of membranes, PPROM, chorioamnionitis, Nitrazine test, ferning, commercial tests, PAMG-1, IGFBP-1 test, ultrasonography, PPROM/antenatal corticosteroids, PPROM/Magnesium sulphate, PPROM/antibiotic treatment, PPROM/tocolysis, PPROM/preterm labour, PPROM/neonatal outcomes, PPROM/mortality, PPROM/outpatient/inpatient, PPROM/cerclage, previable PPROM.

Directive clinique no 430 : Diagnostic et prise en charge de la rupture prématurée des membranes avant terme.

OBJECTIF: Fournir des directives claires et concises pour le diagnostic et la prise en charge de la rupture prématurée des membranes avant terme (RPMAT). POPULATION CIBLE: Toute patiente manifestant une rupture prématurée des membranes avant 37 semaines d'aménorrhée. BéNéFICES, RISQUES ET COûTS: La présente directive clinique vise à fournir les premières recommandations générales canadiennes sur la prise en charge de la rupture des membranes avant terme. Elle repose sur un examen complet et à jour des données probantes sur le diagnostic de la rupture et sur la prise en charge, le bon moment et les modes d'accouchement. DONNéES PROBANTES: Des recherches ont été effectuées dans PubMed-Medline et Cochrane en 2021 en utilisant les termes suivants : preterm premature rupture of membranes, PPROM, chorioamnionitis, Nitrazine test, ferning, commercial tests, PAMG-1, IGFBP-1 test, ultrasonography, PPROM/antenatal corticosteroids, PPROM/Magnesium sulphate, PPROM/antibiotic treatment, PPROM/tocolysis, PPROM/preterm labour, PPROM/neonatal outcomes, PPROM/mortality, PPROM/outpatient/inpatient, PPROM/cerclage, previable PPROM. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des directives cliniques et des études observationnelles. D'autres publications pertinentes ont été sélectionnées à partir des notices bibliographiques de ces articles. Seuls les articles en anglais ont été examinés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Tous les fournisseurs de soins de santé prénatale ou périnatale. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Patient Preferences for Outcomes Associated With Labor Epidural Analgesia.

Purpose Patient preferences for labor epidural analgesia (LEA) have been incompletely evaluated. This study aimed to determine the importance of various LEA outcomes to both antenatal and postpartum patients. Methods This was a cross-sectional study approved by the institutional ethics board. Questionnaires were distributed to two separate and distinct cohorts screened for eligibility: pregnant patients at an antenatal visit and postpartum patients during childbirth admission. A list of common LEA outcomes was compiled using research published in leading anesthesia journals. Participants ranked the outcomes according to perceived importance. They assigned each a number from 1 to 10 (priority ranking; 1 indicated the highest priority outcome and 10 the least). They were also asked to 'spend' $100 towards the outcomes (relative value scale), allocating more money to outcomes more important to them. Results Two hundred twenty questionnaires were completed (105 antenatal, 115 postpartum). 'Achieving desired pain relief' was the most important outcome for both cohorts. It was valued more by the postpartum cohort (Median $50 (25 - 60) vs $30 (18 - 50)). 'Overall satisfaction with the pain management,' 'experiencing a short time to achieve pain relief,' and 'experiencing a short duration of labor' received more money than avoiding various LEA-related side effects. The postpartum cohort ranked 'experiencing a short time to achieve pain relief' as more important than the antenatal cohort (Median 5 (3 - 7) vs 3 (2 - 5)). Conclusions Achieving the desired pain relief was the highest LEA outcome preference for both antenatal and postpartum patients. Avoiding side effects was less important relative to pain-related outcomes.

Clinical Conundrum: To Deliver or Not To Deliver a Patient With Pulmonary Edema and Preeclampsia.

While admitted for management of hyperemesis gravidarum and preeclampsia, a 29-year-old gravida 1 para 0 patient with type 1 diabetes mellitus developed acute shortness of breath at 24 weeks gestation. Physical examination and chest X-ray findings were consistent with pulmonary edema, which in pregnancy is most often a severe complication of preeclampsia warranting delivery. The case is discussed with respect to diagnosis and management of pulmonary edema and acquired pulmonary hypertension in pregnancy, including timing and mode of delivery. Many case studies and guidelines advise caution when embarking on pregnancy with primary pulmonary hypertension; however, there is little available to guide clinical management when pulmonary hypertension secondary to fluid overload and preeclampsia develops during pregnancy.

Interprofessional Patient-Specific Simulation Preparation to Improve Management of Neonatal High-Acuity Low-Occurrence (HALO) Scenarios.

Fetal compressive intrapericardial teratoma is a rare and life-threatening condition, qualifying as a high-acuity low-occurrence (HALO) event. To prepare for delivery and immediate neonatal management, specialists from pediatric cardiology, cardiac surgery, maternal-fetal-medicine, neonatology, cardiac anesthesia, critical care, clinical perfusion, obstetrical nursing, and operating room nursing convened. An in situ operating room simulation was used to identify and introduce key team members, derive and practice the anticipated clinical management algorithm, position human and equipment resources strategically, and ensure that each specialist team was familiar with the environment and available equipment. As rehearsed in the simulation, the cesarean delivery of the patient and neonatal cardiac surgery was uncomplicated and yielded a favourable clinical outcome. A patient-specific HALO simulation preparation (PSHSP) can facilitate positive clinical outcomes and improve health care team confidence in HALO scenarios such as the birth of newborns anticipated to have cardiorespiratory instabilty.

Molar and nonmolar triploidy: Recurrence or bad luck.

In triploid pregnancies, the parental origin of the extra genome determines the phenotype and placental and fetal outcomes. Molecular genetics and placental pathology enable differentiation of molar vs nonmolar pregnancy to guide future planning.

Venous Thromboembolism Manifesting as Sciatica in Two Pregnant Women.

BACKGROUND: Low back pain is a common presentation among pregnant women. CASE: This case report highlights two women who developed excessive low back radicular nerve symptoms during pregnancy as the initial presentation of proximal venous thromboembolism. CONCLUSION: The use of Doppler ultrasound imaging or magnetic resonance imaging is suggested for women presenting with severe clinical symptoms of radicular low back or leg pain in pregnancy to rule out thromboembolism and guide patient management.

Barriers Preventing Medical Students From Performing Pelvic Examinations During Obstetrics and Gynaecology Clinical Clerkship Rotations.

OBJECTIVE: This study sought to identify barriers that prevent medical students from performing pelvic examinations in their obstetrics and gynaecology (Ob/Gyn) clinical clerkship rotations and to compare the perspectives of faculty, residents, nurses, and students regarding perceived barriers. METHODS: An electronic survey was distributed to third-year Dalhousie University (Halifax, NS) medical students on completion of their Ob/Gyn clerkship rotations in the 2015-2016 academic year and to Ob/Gyn nursing staff, faculty, and residents (Canadian Task Force Classification III). RESULTS: There were 82 responses, giving an overall response rate of 28%. Students reported performing an average of 9.2 speculum examinations, 3.8 cervical checks, and 2.8 bimanual examinations during their 6-week rotations. They reported being declined the opportunity to perform an examination an average of 7.1 times. Students perceived themselves to be more competent performing these examinations compared with staff perception of student competency. Students perceived resident interest in teaching, resident and staff time constraints, and patient willingness to have a medical student involved in their examination as frequent barriers. Faculty, residents, and nurses perceived student gender, patient willingness, difficulty of examination, and resident time constraints to be significant barriers. CONCLUSION: This study is the first to examine multidisciplinary perspectives on perceived barriers to medical students performing pelvic examinations. Staff and students have different perceptions of a student's competence performing these examinations. Existing barriers are likely multifactorial.

Sidestream Dark Field Imaging of the Microcirculation to Assess Preeclampsia Microvascular Dysfunction.

BACKGROUND: Development of predictive models of preeclampsia has only yielded modest results. We hypothesized that impaired indices of microcirculatory function could be detected using sidestream dark field imaging. The objective of this study was to examine microvascular function in women at high risk for preeclampsia at mid-gestation. METHODS: Women between 16 and 22 weeks of gestation were screened for eligibility. Patients were recruited if they met eligibility criteria indicating high risk for preeclampsia. Investigators performed non-invasive sidestream dark field imaging of the sublingual microcirculation. Images were analyzed to determine microcirculatory parameters (microvascular flow index, perfused vessel density, total vessel density, and proportion of perfused vessels). After delivery, charts were reviewed to determine if they developed gestational hypertension, preeclampsia or severe preeclampsia. RESULTS: Twelve of 66 participants (18.2%) developed preeclampsia or severe preeclampsia during the course of their pregnancy. Microvascular flow index was not significantly different between participants with normal pregnancies and participants with preeclampsia or severe preeclampsia (2.75 ± 0.38 vs. 2.80 ± 0.34, respectively; P = 0.459). Similarly, there were no significant differences between groups in the remaining microcirculatory parameters. CONCLUSIONS: Sidestream dark field imaging of the sublingual microcirculation may remain an appropriate tool to identify women at risk for preeclampsia, albeit later in pregnancy.

Future Career Plans and Practice Patterns of Canadian Obstetrics and Gynaecology Residents in 2011.

OBJECTIVE: The practice patterns of Obstetricians and Gynaecologists continue to evolve with each new generation of physicians. Diversifying subspecialties, changes in resident duty hours, job market saturation, and desire for work-life balance are playing stronger roles. Professional practice direction and needs assessment may be aided by awareness of future Obstetrics and Gynaecology physician career plans and expectations. The objective of this study was to determine the expected career plans and practice patterns of Canadian Obstetrics and Gynaecology residents following residency. METHODS: The SOGC Junior Member Committee administered its third career planning survey to Canadian Obstetrics and Gynaecology residents electronically in December 2011. The data collected was statistically analyzed and compared to previous surveys. RESULTS: There were 183 responses giving a response rate of 43%. More than one half of all residents were considering postgraduate training (58%). Projected practice patterns included: 84% maintaining obstetrical practice, 60% locuming, and 50% job-sharing. The majority of residents expected to work in a 6 to 10 person call group (48%), work 3 to 5 call shifts per month (72%), work 41 to 60 hours weekly (69%), and practise in a city with a population greater than 500 000 (45%). Only 18% of residents surveyed were in favour of streaming residency programs in Obstetrics and Gynaecology. CONCLUSION: Canadian resident career plan and expected practice pattern assessment remains an important tool for aiding in resource allocation and strategic development of care and training in Obstetrics and Gynaecology in Canada.

A Prospective Cohort Study Using e-Learning Modules as a Supplemental Teaching Resource for Obstetrics and Gynaecology Clerkship Students.

OBJECTIVE: Increasing enrolment in medical schools in Canada has necessitated the development of distributed clinical learning sites to provide appropriate clinical experience. The Faculty of Medicine at Dalhousie University has clinical clerkship sites distributed across Nova Scotia, New Brunswick, and Prince Edward Island, with diverse educational exposures. This study was designed to examine the influence of online learning modules, developed to standardize learning across education sites during the clinical clerkship, on the acquisition of knowledge by medical students during their obstetrics and gynaecology clerkship rotation. METHODS: The third year medical school class was divided into two natural cohorts for the purposes of this study. Group 1 had their obstetrics and gynaecology rotation from September 2012 to March 2013 (n = 54), and Group 2 had their rotation from April to September 2013 (n = 60). All students were given the opportunity to complete an online formative examination before their summative multiple choice examination; only Group 2 students had access to six obstetrics and gynaecology e-learning modules, upon which the formative examination was based. RESULTS: Forty-seven students in Group 1 (87%) and 45 students in Group 2 (75%) completed the formative examination, with an overall participation rate of 81%. There was no difference in median scores between Group 1 (score 9, IQR 8 to 10) and Group 2 (score 9, IQR 8 to 11, P = 0.08). CONCLUSION: Having access to six e-learning modules did not improve the third year medical students' scores on a formative examination completed before their summative multiple choice examination.

Objectif : L'accroissement du nombre des inscriptions aux facultés de médecine canadiennes a rendu nécessaire la mise sur pied de sites satellites d'apprentissage clinique pour offrir une expérience clinique adéquate. La faculté de médecine de l'Université Dalhousie compte des sites de stage clinique qui sont distribués d'un bout à l'autre de la Nouvelle-Écosse, du Nouveau-Brunswick et de l'Île-du-Prince-Édouard, lesquels offrent une diversité d'expositions pédagogiques. Cette étude avait pour but d'examiner l'influence des modules d'apprentissage en ligne (élaborés en vue de standardiser l'apprentissage d'un site de stage clinique à l'autre) sur l'acquisition des connaissances par les étudiants de médecine au cours de leur rotation en obstétrique-gynécologie. Méthodes : Les étudiants de troisième année de médecine ont été répartis en deux cohortes naturelles aux fins de cette étude. La rotation en obstétrique-gynécologie des étudiants du groupe 1 s'est déroulée entre septembre 2012 et mars 2013 (n = 54) et celle des étudiants du groupe 2 s'est déroulée entre avril et septembre 2013 (n = 60). Tous les étudiants se sont vu offrir l'occasion de passer un examen formatif en ligne avant leur examen sommatif à choix multiples; seuls les étudiants du groupe 2 ont eu accès à six modules d'apprentissage en ligne en obstétrique-gynécologie (sur lesquels l'examen formatif a été fondé). Résultats : Quarante-sept étudiants du groupe 1 (87 %) et 45 étudiants du groupe 2 (75 %) ont passé l'examen formatif (taux global de participation : 81 %). Aucune différence n'a été constatée en matière de scores médians entre le groupe 1 (score 9, écart interquartile de 8 à 10) et le groupe 2 (score 9, écart interquartile de 8 à 11, P = 0,08). Conclusion : L'accès à six modules d'apprentissage en ligne n'a pas donné lieu à une amélioration des scores des étudiants de troisième année de médecine dans le cadre d'un examen formatif passé avant l'examen sommatif à choix multiples.

Influence of oligohydramnios on preterm premature rupture of the membranes at 30 to 36 weeks' gestation.

OBJECTIVE: to evaluate the influence of initial oligohydramnios on the prognosis of women with preterm premature rupture of the membranes (PPROM) at 30 to 36 weeks' gestation. METHODS: the Royal Alexandra Hospital ultrasound database was used to identify singleton pregnancies at 30 to 36 weeks' gestation with an ultrasound performed for confirmed PPROM from January 1992 to December 2006. Records were linked to the electronic provincial delivery record to perform a retrospective cohort study comparing the outcomes of pregnancies with an initial amniotic fluid index (AFI) < 5 cm with the outcomes of pregnancies with an AFI of 5 to 10 cm. Logistic and linear regression were used to analyze the association between binary outcome and explanatory variables. RESULTS: the maternal and perinatal outcomes of 438 pregnancies were analyzed. Univariate analysis suggested statistically significant associations between initial oligohydramnios and decreased latency (P < 0.001), increased histologically proven chorioamnionitis (P = 0.01), neonatal length of stay in hospital (P = 0.002), and NICU (P = 0.003); however, after controlling for confounding variables (gestational age at delivery, parity, presentation, and antenatal antibiotic and corticosteroid administration), only latency remained significant (P = 0.004). No association was found between initial oligohydramnios and any other outcomes assessed, including mode of delivery, postpartum endometritis, maternal length of stay, non-reassuring fetal status, and neonatal morbidity and mortality. CONCLUSION: initial oligohydramnios is associated with decreased latency in singleton pregnancies complicated by PPROM at 30 to 36 weeks' gestation; however, it does not appear to influence maternal or neonatal infectious morbidity, and it may not be useful to determine candidacy for expectant management or intentional delivery.

Society of obstetricians and gynaecologists of Canada junior member committee survey: future career plans of Canadian obstetrics and gynaecology residents.

OBJECTIVE: Although the SOGC Strategic Directions 2006-2011 includes a commitment to the development of a human resource strategy for obstetrical and gynaecological care, little is known about the career plans of Canadian obstetrics and gynaecology residents. If we are to determine the needs of our profession, we must be aware of the expected practice patterns of future women's health care providers. The primary objective of this study was to evaluate the future career plans of Canadian obstetrics and gynaecology residents. METHODS: The SOGC Junior Member Committee administered two career surveys to Canadian obstetrics and gynaecology residents. The first was directly distributed to all Canadian residents and collected by local representatives of the SOGC Junior Member Committee in November 2002. The second was electronically administered from November 2005 to January 2006. The data collected from the surveys were collated and analyzed using statistical analysis software. RESULTS: The first survey, in 2002, was completed by 236 obstetrics and gynaecology residents (68% response rate) and the second, in 2006, by 246 (65% response rate). In both surveys, respondents were evenly distributed over all five years of residency training and all residency training programs. In 2002, 63 residents (30%) were considering additional postgraduate fellowship training following completion of residency compared with 130 residents (53%) in 2006 (P < 0.001). In both surveys, senior residents (postgraduate years IV and V) were significantly less likely to consider further postgraduate training than residents in their first three years (2002: 17% vs. 38%; 2006: 42% vs. 58%). Of total respondents to the 2002 and 2006 surveys, 87% planned to practice obstetrics upon graduation. The 2006 survey also found that the majority of residents desired to work in call groups of 6 to 10 physicians, work three to five on-call shifts per month, and work a 40- to 60-hour week; 44% of residents planned work as locums after graduation. CONCLUSION: Recognition of the planned practice patterns of our current residents may assist in the development of an appropriate human resource strategy for future obstetrical and gynaecological care in Canada.

Fetus-in-fetu: confirmation of prenatal diagnosis with MRI.

Fetus-in-fetu is a rare form of monozygotic diamniotic twin pregnancy in which one fetus is enclosed within its twin (Khadaroo et al., 2000). This case report highlights the use of prenatal MRI to confirm prenatal diagnosis of an intra-abdominal FIF to aid obstetricians, neonatologists, and pediatric general surgeons in perinatal and surgical management.