A retrospective analysis of postpartum red blood cell transfusions at a tertiary care obstetric centre.

BACKGROUND AND OBJECTIVES: Postpartum anaemia is a prevalent health problem. We aimed to determine the compliance rate for red blood cell (RBC) transfusion indication among postpartum women in a single tertiary care centre in Quebec, Canada. MATERIALS AND METHODS: Retrospective cohort study including all women ≥6 h postpartum who received ≥1 RBC transfusion during their delivery hospitalization between January 2005 and February 2022. We determined our centre's compliance rate by indication as compared to current society guidelines, all published after 2015 (Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis [NATA], Royal College of Obstetricians and Gynaecologists [RCOG], American College of Obstetricians and Gynecologists [ACOG]). We then explored predictors of guideline non-compliance and described transfusion practices in our centre. RESULTS: A total of 171 women were included. Our centre's compliance rate was 79.5% (95% confidence interval [CI] 72.7-84.8). Predictors of guideline non-compliance were maternal medical comorbidity or abnormal placentation, both limited by large CIs (odds ratio [OR] 2.26, CI 1.02-4.94, p = 0.04; OR 4.00, CI 1.31-12.06, p = 0.01, respectively). Postpartum haemorrhage was diagnosed among 68% of the cohort, mostly due to uterine atony (73.3%). Mean baseline and nadir haemoglobin were 111 g/L (±18) and 62 g/L (±7.7), respectively. Multiple unit initial transfusion was found in a majority of patients (63.7%). Iron therapy was administered to 51.5% of women in-hospital and 81.9% received an oral iron prescription at discharge. There were no differences in primary or secondary outcomes subsequent to relevant guideline publication. CONCLUSION: Our centre's compliance rate for RBC transfusion indication meets current practice guidelines. Areas for improvement include single-unit initial transfusion protocols and adjuvant iron treatment. Antenatal optimization of haemoglobin and ferritin stores may limit postpartum transfusions.

Mode of delivery is an independent risk factor for maternal mortality: a case-control study.

BACKGROUND AND OBJECTIVES: In contrast to the global trend, the maternal mortality ratio (MMR) in the United States has increased in recent decades. During this time, the cesarean section rate has concurrently and steadily increased. Herein, we sought to determine whether the mode of delivery is an independent risk factor for maternal in-hospital mortality. MATERIALS AND METHODS: We conducted a retrospective, population-based, 1:1 matched, case-control study on all births recorded in the Health - Care Cost and Utilization Project - Nationwide Inpatient Sample between 2005 and 2014. We compared cases of maternal mortality and survival on a number of clinical characteristics. We conducted two different multivariate logistic regression analysis models, obtaining the adjusted odds ratios to determine the independent effect of mode of delivery on maternal mortality relative to surviving controls. RESULTS: We found a total of 617 cases of maternal mortality, which corresponds to an in-hospital MMR of 6.9/100,000 in our cohort. We matched 617 controls to mortality cases by year and geographic location. Relative to surviving controls, cases of maternal mortality were older, more likely to be African American, of lesser income, more likely to use Medicaid as payment, to have prolonged admissions, and more likely to have severe obstetrical complications including preterm delivery, postpartum hemorrhage, eclampsia, peripartum cardiomyopathy, pulmonary emboli, and disseminated intravascular coagulation (DIC). Relative to unassisted vaginal delivery, adjusted logistic regression analysis reveals no excess mortality observed with assisted vaginal delivery: OR 1.35, 95% CI [0.59-3.51]. However, after adjusting for demographic and obstetrical confounders, a significant risk of maternal mortality was observed with cesarean delivery: OR 3.21, 95% CI [2.80-3.61], p-value = .0001. This risk was more pronounced amongst primary cesarean deliveries: OR 5.72, 95% CI [4.92-6.51], p-value = .0001. CONCLUSION: Cesarean delivery, and particularly primary cesarean delivery, is an independent risk factor for maternal in-hospital mortality. Measures taken to reduce the cesarean section rate may impact the rising maternal mortality ratio (MMR) in the United States.

Cardiopulmonary Function Abnormalities in Cohort of Adults following Bronchopulmonary Dysplasia as Preterm Infants.

OBJECTIVE: This study was aimed to describe the cardiopulmonary profiles of adult patients with bronchopulmonary dysplasia (BPD), comparing them to normative adult values. STUDY DESIGN: This study presents a retrospective chart review of all BPD patients followed in the adult BPD clinic, identified from institutional and archive databases, born preterm at ≤33 weeks of estimated gestational age (EGA) between January 1980 and December 2000. RESULTS: Forty-four patients with BPD (26.4 ± 2.7 weeks of EGA) were included. Average age at follow-up was 19 years. Majority (61.4%) of the patients had a diagnosis of asthma. Mean spirometry values were: first second of forced expiration (FEV1) 74.1%, forced vital capacity (FVC) 80.7%, and FEV1/FVC 82.5%. Echocardiography (ECHO) images were reviewed, left ventricular (LV) structure and performance did not differ between obstructive and nonobstructive pulmonary function test (PFT) groups, but values of LV longitudinal strain were 4.8% lower than expected normal for adults. Patients with obstructive PFT had additional decreased right ventricular (RV) function by ECHO. CONCLUSION: BPD patients in this study were found to have a burden of cardiorespiratory alterations that persisted into adulthood, with RV performance abnormalities found among patients with obstructive PFT. KEY POINTS: · BPD patients born at extremes of prematurity have cardiorespiratory alterations in adulthood.. · Among patients with obstructive lung function, subtle cardiac performance abnormalities were found.. · Future directions should include systematic follow-up of premature newborns with BPD..

Prevalence threshold of screening tests in obstetrics and gynecology.

OBJECTIVE: We define the prevalence threshold as the prevalence level below which a test's positive predictive value (PPV) declines most sharply relative to disease prevalence - and thus the rate of false positive results/false discovery rate increases most rapidly. The objective of this study is to determine the prevalence threshold of various screening tests used in obstetrics and gynecology among low-risk women in modern clinical practice. METHODS: We searched Medline, EMBASE, Google Scholar, Scopus, ISI Web of Science, Cochrane database, and PubMed to obtain the sensitivity and specificity estimates for the following screening tests: 50 g-oral glucose tolerance test (GDM-50 g), non-invasive prenatal testing (NIPT), combined first trimester screening (FTS), vagino-rectal swab for group B streptococcus (GBS) in pregnancy, cervical cytology (Pap) and HPV testing, mammography and manual breast exam, urinary PCR and cervical-vaginal swab testing for gonorrhoea and chlamydia as well as AMH for the diagnosis of PCOS. We used these estimates to calculate disease-specific prevalence thresholds, comparing them to the actual estimates of disease prevalence. RESULTS: The prevalence thresholds and average estimates of disease prevalence (shown in brackets) are as follows: GDM-50 g 31 % (6%), NIPT 7% (0.2 %), combined FTS 19.5 % (0.2 %), GBS swab 18 % (15-45 %), Pap 21 % (0.2 %), HPV 27 % (0.2 %), mammography 25 % (12.5 %), breast exam 25 % (12.5 %), gonorrhoea -chlamydia 6-13 % (4.2-4.7 %), AMH for PCOS 32 % (10 %). CONCLUSION: The prevalence thresholds of various screening tests used in obstetrics and gynecology are well above the estimated disease prevalence. This implies that when undertaking population-level screening a significant proportion of positive screening tests obtained are likely false-positives. Attempts at individualizing pre-test probability when undertaking population-level screening are needed in order to best interpret the results of screening tests.

The Montreal Criteria and uterine transplants in transgender women.

Ever since its first documented live birth in 2014, the use of uterine transplantation (UTx) for the treatment of absolute uterine factor infertility (UFI) has seen major clinical advances, which include the use of alternative surgical approaches, different donor states, and diverse patient populations. In addition to the thorough research programs that developed the technique, this accomplishment has occurred in large part following a number of ethical frameworks, such as the Montreal Criteria and the Indianapolis Consensus, which paved the way to transition from experimental animal trials to human ones. To date, over 60 uterine transplants have been performed in the world, and at least 18 births have been thus far confirmed. While the procedure remains experimental, the vast knowledge and procedural experience amassed over the last 20 years of rigorous research have hinted at the next step of discovery. In particular, advancing social circumstances have prompted the question regarding the use of this technology in transgender individuals. Though the potential use of uterine transplants in the transgender population has been hypothesized, no in-depth ethical framework has been developed towards this purpose. Herein, we explore the ethical issues revolving around the use of this technology in this patient population and provide key insights that may advance this cause.

Non-medical cannabis use among Indigenous Canadians: A systematic review of prevalence and associated factors.

BACKGROUND: Indigenous Canadians may be at an increased risk of non-medical cannabis use. The aim of this review was to synthesize the prevalence of non-medical cannabis use and its associated factors among Indigenous Canadians. METHODS: We systematically searched MEDLINE, EMBASE, Web of Science, and Scopus from inception to January 29th, 2020 for publications reporting the prevalence of non-medical cannabis use among Indigenous Canadians. We included studies published in English after January 1st, 2000. Included publications were hand-searched for potentially relevant peer-reviewed and gray literature publications. Results were synthesized descriptively. RESULTS: We identified 16 peer-reviewed and 7 gray literature publications which met our inclusion criteria. All data were collected prior to cannabis legalization in Canada (October 17th, 2018). The most recent estimates of prevalence of use in the past year were 27% among on-reserve First Nations adults, 50% among off-reserve First Nations adults, and 60% among Nunavik Inuit. In youth, they were 45% among all Indigenous youth grades 9-12, 27% among on-reserve First Nations youth aged 12-17, and 69% in Nunavik Inuit aged 16-22. Direct comparisons indicated a 1.2-15 times higher prevalence of use in Indigenous compared to non-Indigenous youth. Factors associated with cannabis use in adults included younger age and male sex. In youth, factors included older age, poorer mental and physical health, and a poorer relationship with school. CONCLUSION: Results suggest that Indigenous Canadians are at a higher risk for non-medical cannabis use than the general Canadian population. Further research is warranted to inform the development of targeted interventions.

Ever-use of the intra-uterine device and the risk of ovarian cancer.

The association between the use of the intra-uterine device (IUD) and the risk of ovarian cancer is not well known. In this study, we sought to determine whether the use of an IUD is associated with a reduction in the risk of ovarian cancer. We searched Medline, EMBASE, Google Scholar, Scopus, ISI Web of Science and Cochrane database search, as well as PubMed (www.pubmed.gov) and RCT registry (www.clinicaltrials.gov) until the end of June 2019 to conduct a systematic review and meta-analysis comparing ever-use vs. never-use of an IUD and the risk of subsequent ovarian cancer. We obtained 431 records, of which 9 met inclusion criteria. A total of five case-control studies and four cohort studies were retrieved to establish the risk of ovarian cancer amongst ever-users of an IUD. Relative to the never-use of the IUD, ever-use conferred a lower risk of ovarian cancer with an estimated OR of 0.67 95% CI [0.60 - 0.74], p < .0001, I2 = 71%. This relationship remained significant when results were restricted to studies evaluating the levonorgestrel intrauterine system (LNG-IUD) alone, with an estimated OR of 0.58 95% CI [0.47 - 0.71], p < .0001, I2 = 0%, as well as when the analysis was stratified by study design, with an OR of 0.64 95% CI [0.56 - 0.74] for case-control studies, and OR of 0.71 95% CI [0.60 - 0.84] for cohort studies (p < .0001). Ever-use of an intrauterine contraceptive device reduces the risk of ovarian cancer by an average of 30%. Whether differences exist for duration of use, use of type-specific device, and specific tumour type needs to be addressed in future studies.Impact statementWhat is already known on this subject? The use of IUDs is very common practice in today's society. Its benefits regarding contraception, the treatment of abnormal uterine bleeding and even the reduction of the rates of endometrial cancer are well established. However, whether IUD's are associated with a reduction in the risk of ovarian cancer is unknown.What do the results of this study add? In this study, we show that the ever-use of the IUD reduces the risk of ovarian cancer by an average of 30%. We provide insight regarding the potential theories that may underlie these findings.What are the implications of these findings for clinical practice and/or further research? future studies will need to determine whether the beneficial effects found are a function of duration of use, of type-specific device, or specific tumour types. In the meantime, these findings may serve clinicians to reassure and counsel patients about the added benefits of intra-uterine devices.

Use of Placental Growth Factor for Trisomy 21 Screening in Pregnancy: A Systematic Review.

Background Prenatal serum screening is an important modality to screen for aneuploidy in pregnancy. The addition of placental growth factor (PLGF) to screen for trisomy 21 remains controversial. Objective To determine whether the addition of PLGF to combined serum aneuploidy screening improves detection rates (DRs) for trisomy 21. Study Design We performed a systematic review of the literature until October 2019 to determine the benefits of adding PLGF to prenatal screening. We performed a goodness-of-fit test and retrieved the coefficient of determinations ( R 2 ) as a function of false positive rates (FPRs), providing mean-weighted improvements in the DRs after accounting for PLGF levels. Results We identified 51 studies, of which 8 met inclusion criteria (834 aneuploidy cases and 105,904 euploid controls). DRs were proportional to FPR across all studies, ranging from 59.0 to 95.3% without PLGF and 61.0 to 96.3% with PLGF (FPR 1-5%). Goodness-of-fit regression analysis revealed a logarithmic distribution of DRs as a function of the FPR, with R 2 = 0.109 (no PLGF) and R 2 = 0.06 (PLGF). Two-sample Kolmogorov-Smirnov's test reveals a p -value of 0.44. Overall, addition of PLGF improves DRs of 3.3% for 1% FPR, 1.7% for 3% FPR, and 1.4% for 5% FPR, respectively. Conclusion Addition of PLGF to prenatal screening using serum analytes mildly improves trisomy 21 DRs as a function of FPRs.

Bayes Theorem and Protopathic Bias: Methodological Concerns When Addressing the Impact of Fetal Heart Rate Patterns on the Cesarean Section Rate.

Over the last 30 years, the caesarean section rate has reached global epidemic proportions. This trend is driven by multiple factors, an important one of which is the use and inconsistent interpretation of the electronic fetal monitoring (EFM) system. Despite its introduction in the 1960s, the EFM has not definitively improved neonatal outcomes, yet it has since significantly contributed to a seven-fold increase in the caesarean section rate. As we attempt to reduce the caesarean rates in the developed world, we should consider focusing on areas that have garnered little attention in the literature, such as physician sensitization to the poor predictive power of the EFM and the research method biases that are involved in studying the abnormal heart rate patterns-umbilical cord pH relationship. Herein, we apply Bayes theorem to different clinical scenarios to illustrate the poor predictive power of the EFM, as well as shed light on the principle of protopathic bias, which affects the classification of research outcomes among studies addressing the effects of the EFM on caesarean rates. We propose and discuss potential solutions to the aforementioned considerations, which include the re-examination of guidelines with which we interpret fetal heart rate patterns and the development of noninvasive technologies that evaluate fetal pH in real time.

Use of Tranexamic Acid for the Treatment of Mittelschmerz in a Patient with Type 1 von Willebrand Disease and Recurrent Hemorrhagic Cysts.

BACKGROUND: Tranexamic acid reduces blood loss in patients with bleeding diatheses and is used in a number of gynaecologic and non-gynaecologic conditions CASE: We discuss the case of a 27-year-old woman with type 1 von Willebrand disease, who presented with a two-year history of severe mittelschmerz secondary to recurrent hemorrhagic cysts. The patient refused oral contraception and reported that traditional analgesia did not significantly alleviate symptoms. We theorized that the underlying von Willebrand disease compounded the degree of hemorrhage into her recurrent cysts. As such, a trial of mid-cycle tranexamic acid was offered, which drastically improved her symptoms. CONCLUSION: We report that the use of mid-cycle tranexamic acid in patients with recurrent haemorrhagic cysts can lower ovulation-associated pain.