Spasticity Management Teams, Evaluations, and Tools: A Canadian Cross-Sectional Survey.

OBJECTIVE: The objective of this study is to determine the physical evaluations and assessment tools used by a group of Canadian healthcare professionals treating adults with spasticity. METHODS: A cross-sectional web-based 19-question survey was developed to determine the types of physical evaluations, tone-related impairment measurements, and assessment tools used in the management of adults with spasticity. The survey was distributed to healthcare professionals from the Canadian Advances in Neuro-Orthopedics for Spasticity Congress database. RESULTS: Eighty study participants (61 physiatrists and 19 other healthcare professionals) completed the survey and were included. Nearly half (46.3%, 37/80) of the participants reported having an inter- or trans-disciplinary team managing individuals with spasticity. Visual observation of movement, available range of motion determination, tone during velocity-dependent passive range of motion looking for a spastic catch, spasticity, and clonus, and evaluation of gait were the most frequently used physical evaluations. The most frequently used spasticity tools were the Modified Ashworth Scale, goniometer, and Goal Attainment Scale. Results were similar in brain- and spinal cord-predominant etiologies. To evaluate goals, qualitative description was used most (37.5%). CONCLUSION: Our findings provide a better understanding of the spasticity management landscape in Canada with respect to staffing, physical evaluations, and outcome measurements used in clinical practice. For all etiologies of spasticity, visual observation of patient movement, Modified Ashworth Scale, and qualitative goal outcomes descriptions were most commonly used to guide treatment and optimize outcomes. Understanding the current practice of spasticity assessment will help provide guidance for clinical evaluation and management of spasticity.

Type of Labour in the First Pregnancy and Cumulative Perinatal Morbidity.

OBJECTIVE: To estimate cumulative perinatal morbidity among infants delivered at term, according to the type of labour in the first pregnancy, when the first pregnancy was low risk. METHODS: In a 26-year population-based cohort study (1988-2013) using the Nova Scotia Atlee Perinatal Database, we identified the type of labour in successive pregnancies in low-risk, nulliparous women at term in their first pregnancy (who had at least one subsequent pregnancy), and also identified perinatal outcomes in subsequent deliveries according to the type of labour in the first pregnancy. RESULTS: A total of 37 756 pregnancies satisfied inclusion and exclusion criteria; of these, 1382 (3.7%) had a Caesarean section without labour in the first pregnancy. Rates of most adverse perinatal outcomes were low (≤ 1%). The risks for stillbirth were low in subsequent deliveries, including those that followed CS without labour in the first pregnancy, and the risks for the overall severe perinatal morbidity outcome were less than 10% for all subsequent deliveries. CONCLUSION: The absolute risks for severe perinatal morbidity outcomes in a population of low-risk women (with up to four additional pregnancies) were small, regardless of type of labour in the first pregnancy. This finding provides important information on perinatal outcomes in subsequent pregnancies when considering type of labour in the first pregnancy.

Is Preterm Premature Rupture of Membranes Latency Influenced by Single Versus Multiple Agent Antibiotic Prophylaxis in Group B Streptococcus Positive Women Delivering Preterm?

OBJECTIVE: To evaluate the influence of antibiotic regimen on the duration of latency (time from preterm pre-labour rupture of membranes [PPROM] to delivery) and significant infectious neonatal morbidity from rupture of membranes to delivery < 37 weeks' gestational age in women known to be group B Streptococcus (GBS) positive. METHODS: We obtained data from the Nova Scotia Atlee Perinatal Database. In a retrospective, cohort, population-based study, we included pregnancies complicated by PPROM but excluded pregnancies in this group requiring immediate delivery. The cohort was categorized by antibiotic regimen (single vs. multiple agents) and we compared latency and adverse neonatal outcomes according to antibiotic regimen used. Summary characteristics were compared using chi-square analysis with significance < 0.05. Logistic regression was used to estimate adjusted odds ratios, 95% confidence intervals, and mean differences for all outcomes and to account for confounding variables. RESULTS: From 1988 to 2011, the potential study population was 119 158 pregnancies. In total, 3435 deliveries were identified to be PPROM (3%). Of these, 303 mother-baby pairs (9%) were known to be GBS positive by urine or swab culture. Adjusted comparisons of latency and neonatal sepsis showed no difference according to antibiotic regimen (P > 0.05). CONCLUSION: The 2013 SOGC guideline on GBS prophylaxis recommends antibiotic therapy in women with PPROM for both latency and prevention of GBS-related neonatal sepsis. This clinically relevant evaluation in a select preterm group demonstrated that type of antibiotic regimen did not influence either latency with PPROM and GBS positive culture or rates of neonatal sepsis. Ongoing evaluation of serious neonatal outcomes is essential in view of this new recommendation.

Objectif : Évaluer l'influence d'un schéma antibiotique sur la durée de la latence (période séparant la rupture prématurée des membranes préterme [RPMP] et l'accouchement) et la présence d'une morbidité infectieuse néonatale considérable, entre la rupture des membranes et l'accouchement à < 37 semaines d'âge gestationnel, chez des femmes ayant obtenu des résultats positifs au dépistage des streptocoques du groupe B (SGB). Méthodes : Nous avons tiré des données de la Nova Scotia Atlee Perinatal Database. Dans le cadre d'une étude populationnelle de cohorte rétrospective, nous avons inclus les grossesses compliquées par la RPMP, mais nous avons exclu les grossesses de ce groupe qui nécessitaient un accouchement immédiat. La cohorte a été catégorisée en fonction du schéma antibiotique (un seul agent vs de multiples agents) et nous avons comparé la latence et les issues néonatales indésirables en fonction du schéma antibiotique utilisé. Les caractéristiques sommaires ont été comparées au moyen d'une analyse du chi carré (signification < 0,05). Une régression logistique a été utilisée pour estimer les rapports de cotes corrigés, les intervalles de confiance à 95 % et les différences moyennes pour toutes les issues et pour tenir compte des variables parasites. Résultats : Entre 1988 et 2011, la population d'étude potentielle s'élevait à 119 158 grossesses. Au total, 3 435 accouchements ont été identifiés comme présentant une RPMP (3 %). La présence de SGB avait été déterminée par uroculture ou par mise en culture d'écouvillonnages chez 303 paires mère-enfant (9 %) de ce groupe. Les comparaisons corrigées de la latence et de la septicémie néonatale n'ont indiqué aucune différence en fonction du schéma antibiotique (P > 0,05). Conclusion : La directive de 2013 de la SOGC sur la prophylaxie anti-SGB recommande la mise en œuvre d'une antibiothérapie chez les femmes qui présentent une RPMP, et ce, tant pour la latence que pour la prévention de la septicémie néonatale attribuable aux SGB. Cette évaluation pertinente sur le plan clinique auprès d'un groupe sélectionné d'accouchements prétermes a démontré que le type de schéma antibiotique n'influençait ni la latence (en présence d'une RPMP et de résultats positifs à la suite de la mise en culture des SGB) ni les taux de septicémie néonatale. La poursuite de l'évaluation des issues néonatales graves s'avère essentielle à la lumière de cette nouvelle recommandation.

Type of Labour in the First Pregnancy and Cumulative Maternal Morbidity.

OBJECTIVE: To estimate cumulative maternal morbidity among women who delivered at term in their first pregnancy on the basis of type of labour in the first pregnancy. METHODS: Using a 25-year population-based cohort (1988 to 2012) derived from the Nova Scotia Atlee Perinatal Database, we determined the type of labour in successive pregnancies in low-risk, nulliparous women at term in their first pregnancy (who had at least one subsequent pregnancy), and the maternal outcomes in subsequent deliveries based on the type of labour in the first pregnancy. RESULTS: A total of 36 871 pregnancies satisfied inclusion and exclusion criteria, 1346 of which were delivered by Caesarean section without labour in the first pregnancy. Rates of most adverse maternal outcomes were low (≤1%). The type of labour in the first pregnancy influenced the subsequent risk of postpartum hemorrhage and blood transfusion, and the risks increased with successive deliveries when labours were spontaneous in onset or were induced. The risks for abnormal placentation were low with subsequent deliveries, including following CS without labour in the first pregnancy, and risks for overall severe maternal morbidity were less than 10% for all subsequent deliveries. CONCLUSION: The absolute risks for severe maternal morbidity outcomes in a population of women without a high number of subsequent pregnancies were small (regardless of type of labour in the first pregnancy); this provides important information for women, families, and caregivers when considering pregnancy outcomes related to type of labour.

Objectif : Estimer la morbidité maternelle cumulative chez les femmes qui ont accouché à terme dans le cadre de leur première grossesse, en fonction du type de travail au cours de celle-ci. Méthodes : En utilisant une étude de cohorte de 25 ans en population générale (de 1988 à 2012) issue de la Nova Scotia Atlee Perinatal Database, nous avons déterminé le type de travail dans le cadre des grossesses successives chez des femmes exposées à de faibles risques qui ont accouché à terme dans le cadre de leur première grossesse (et qui ont connu au moins une autre grossesse), ainsi que les issues maternelles dans le cadre des accouchements subséquents, en fonction du type de travail dans le cadre de la première grossesse. Résultats : Au total, 36 871 grossesses ont satisfait aux critères d'inclusion et d'exclusion (dont 1 346 qui se sont soldées en une césarienne sans travail dans le cadre de la première grossesse). Les taux de la plupart des issues indésirables maternelles étaient faibles (≤ 1 %). Le type de travail dans le cadre de la première grossesse a exercé une influence sur le risque subséquent d'hémorragie postpartum et de transfusion sanguine; de plus, les risques ont connu une hausse dans le cadre des accouchements successifs lorsque le travail était spontané ou qu'il était déclenché. Les risques de placentation anormale étaient faibles dans le cadre des accouchements subséquents, y compris à la suite d'une césarienne sans travail dans le cadre de la première grossesse; les risques de morbidité globale grave chez la mère étaient inférieurs à 10 % pour tous les accouchements subséquents. Conclusion : Au sein d'une population de femmes n'ayant pas connu un nombre élevé de grossesses subséquentes, les risques absolus de morbidité maternelle grave étaient faibles (peu importe le type de travail dans le cadre de la première grossesse); cela offre d'importants renseignements aux femmes, aux familles et aux soignants lorsque les issues de grossesse sont envisagées en fonction du type de travail.

Trends in the prevalence of cerebral palsy among very preterm infants (<31 weeks' gestational age).

BACKGROUND: The birth prevalence of cerebral palsy varies over time among very preterm infants, and the reasons are poorly understood. OBJECTIVE: To describe the variation in the prevalence of cerebral palsy among very preterm infants over time, and to relate these differences to other maternal or neonatal factors. METHODS: A population-based cohort of very preterm infants was evaluated over a 20-year period (1988 to 2007) divided into four equal epochs. RESULTS: The prevalence of cerebral palsy peaked in the third epoch (1998 to 2002) while mortality rate peaked in the second epoch (1993 to 1997). Maternal anemia, tocolytic use and neonatal need for home oxygen were highest in the third epoch. CONCLUSIONS: Lower mortality rates did not correlate well with the prevalence of cerebral palsy. Maternal risk factors, anemia and tocolytic use, and the newborn need for home oxygen were highest during the same epoch as the peak prevalence of cerebral palsy.

HISTORIQUE: La prévalence de paralysie cérébrale à la naissance varie au fil du temps chez les nourrissons très prématurés, et on en comprend mal les raisons. OBJECTIF: Décrire la variation de la prévalence de paralysie cérébrale chez les nourrissons très prématurés au fil du temps et les relier à d'autres facteurs relatifs à la mère ou à la période néonatale. MÉTHODOLOGIE: Les chercheurs ont évalué une cohorte de nourrissons très prématurés sur 20 ans (1988 à 2007), divisée en quatre périodes d'égale longueur. RÉSULTATS: La prévalence de paralysie cérébrale a atteint un pic pendant la troisième période (1998 à 2002), tandis que le pic du taux de mortalité est survenu pendant la deuxième période (1993 à 1997). L'anémie et l'utilisation de tocolytiques chez la mère, ainsi que l'assistance ventilatoire néonatale à domicile, étaient plus élevées pendant la troisième période. CONCLUSIONS: Les taux de mortalité plus faibles n'étaient pas bien corrélés avec la prévalence de paralysie cérébrale. Les facteurs de risque de la mère, c'est-à-dire l'anémie et l' utilisation de tocolytiques, de même que l'assistance ventilatoire du nouveau-né à domicile, étaient tous plus élevés pendant la période qui s'associait à la plus forte prévalence de paralysie cérébrale.

Fetal movement monitoring: how are we doing as educators?

OBJECTIVE: When decreased fetal movement is noticed, delay in seeking care is associated with poor perinatal outcomes, including stillbirth. Health care providers are responsible for educating women about normal fetal movement and the appropriate actions they should take if it decreases. This study aimed to demonstrate our pregnant population's understanding of normal fetal movement and responses to decreased fetal movement, and to potentially guide educational interventions to improve perinatal outcomes. METHODS: We surveyed 304 pregnant women (over 26 weeks' gestation) during clinic visits at the IWK Health Centre, Halifax, NS. Information collected in the survey included demographics, knowledge about normal fetal movement, monitoring techniques, and response to decreased fetal movement. RESULTS: Eighteen percent of women (55/298) demonstrated knowledge of normal fetal movement and fetal monitoring, indicating that they would seek assessment promptly if they experienced decreased fetal movement. Although 54.7% of participants (164/300) would contact a health care professional if they noticed decreased fetal movement, approximately two thirds of participants were unable to describe normal fetal movement or monitoring techniques. Almost 30% of participants (90/304) did not identify daily fetal movement as normal, and 37.5% (114/304) reported it may be normal for fetal movement to stop around their due date. Written and verbal communication regarding fetal movement from a health care provider significantly increased the likelihood of appropriate intended self-management in the context of decreased fetal movement. CONCLUSION: Education influences the anticipated behaviour of pregnant women regarding decreased fetal movement. Specific areas of misinformation which may guide future education strategies are identified. There is room for improvement in this area of patient education.

Neonatal outcome following failed Kiwi OmniCup vacuum extraction.

OBJECTIVE: To evaluate neonatal outcomes following failed vacuum extraction using the Kiwi OmniCup vacuum device. METHODS: We conducted a retrospective study of 288 failed vacuum deliveries using the OmniCup device. The neonatal morbidity was recorded for each delivery. RESULTS: Of the 288 women involved, 82.3% were nulliparous. In 245 cases (85.1%), failed vacuum was followed by successful forceps delivery; failed vacuum and failed forceps was followed by Caesarean section in 5.9%; failed vacuum was followed by spontaneous vaginal delivery in 3.8%; and failed vacuum was followed by Caesarean section in 5.2%. Cephalhematoma was diagnosed in 19.8% of the 288 infants delivered. There were no cases of neonatal intracranial or subgaleal hemorrhage. CONCLUSION: Although the method of delivery following failed vacuum extraction is controversial, and most national guidelines warn of increased neonatal morbidity with subsequent use of forceps, the low morbidity in this study is reassuring. In our cohort, low forceps delivery (station > 2 cm) following failed vacuum extraction was not associated with serious neonatal morbidity.

Prevalence of atrial fibrillation in patients taking TSH suppression therapy for management of thyroid cancer.

BACKGROUND: Suppression of thyroid stimulating hormone (TSH) below the normal range with administration of L-thyroxine has been shown to improve survival in patients treated for thyroid cancer (TC). Although most TC patients require long-term TSH suppression therapy, the effect of this treatment on cardiac rhythm remains unknown. A cross-sectional study was conducted to determine the prevalence of atrial fibrillation (AF) in TC patients on TSH suppressive therapy. METHODS: All TC patients seen between June 2009 and March 2010 through a multidisciplinary thyroid oncology clinic, Halifax, Nova Scotia, Canada, for whom TSH suppressive therapy had previously been recommended, were recruited into the study. Each patient underwent an electrocardiogram and filled out a questionnaire relevant to causes, signs/symptoms of AF and/or its complications. The prevalence of AF in this population then was compared against the published prevalence of AF in general populations. RESULTS: A total of 351 patients were seen in the thyroid clinic of which 136 patients met the inclusion criteria for the study. The mean age was 52 years, 85% were female, and mean follow-up duration prior to recruitment was 11 years. The mean TSH was 0.17 mIU/L (Normal: 0.35 - 5.5 mIU/L). There were 14 patients found to have AF (two patients had long-standing persistent AF and 12 patients had paroxysmal AF). The mean ages of patients with and without AF were 61.6 years and 51.4 years, respectively (P = 0.01). Prevalence of AF in the study group was 10.3%; the rate of AF in the TC patients aged 60 years and over (17.5%) was higher than the rate of AF in published data in people 60 years and over (P < 0.001). AF was diagnosed after the initiation of the TSH suppression therapy in all except one patient. CONCLUSION: TSH suppression in thyroid cancer is associated with a high prevalence of AF, particularly in older individuals.

The influence of changing post-term induction of labour patterns on severe neonatal morbidity.

OBJECTIVE: To estimate the influence of changing practice patterns of post-term induction of labour on severe neonatal morbidity. METHODS: This population-based cohort study used data from the Nova Scotia Atlee Perinatal Database to evaluate the effect of post-term induction of labour on stillbirth and neonatal mortality and severe neonatal morbidity in low-risk pregnancies. The study population included all pregnant women ≥ 40 weeks' gestation delivering in Nova Scotia from 1988 to 2008 who underwent induction of labour with a single fetus in cephalic presentation. Major congenital anomalies and pre-existing or severe gestational hypertension and diabetes were excluded. Women delivering post-term from 1994 to 2008 (after the Post-term Pregnancy Trial) were compared with women delivering from 1988 to 1992 to evaluate outcomes with changing maternal characteristics and obstetric practice patterns. RESULTS: Evaluation and comparison of time epochs (1988 to 1992, 1994 to 1998, 1999 to 2003, and 2004 to 2008) demonstrated an increased risk for perinatal mortality or severe neonatal morbidity, especially low five-minute Apgar score, among both nulliparous and multiparous women. There were no significant differences in the risks for stillbirth or perinatal mortality over time. Comparable relationships were demonstrated in a subgroup of lower risk women. CONCLUSION: The increase in post-term induction of labour with time is associated with a significant increase in severe neonatal morbidity, especially among infants born to multiparous women. Evaluation of the antepartum and intrapartum management of these low-risk pregnancies may provide additional information to reduce morbidity.

Acute disseminated intravascular coagulation in obstetrics: a tertiary centre population review (1980 to 2009).

OBJECTIVE: To determine the antecedent factors, morbidity, and mortality associated with disseminated intravascular coagulation (DIC) in a Nova Scotia tertiary maternity hospital over a 30-year period. METHODS: Cases of DIC were identified from the Nova Scotia Atlee Perinatal Database for the years 1980 to 2009 and the hospital charts reviewed. The clinical diagnosis of DIC was confirmed or refuted using a combination of the International Society of Thrombosis and Haemostasis scoring system and an obstetrical DIC-severity staging system. The cause of DIC was determined from chart review. Maternal outcomes included massive transfusion (≥ 5 units), hysterectomy, admission to ICU, acute tubular necrosis (ATN) requiring dialysis, and death. Neonatal outcomes included Apgar scores, birth weight, NICU admission, and death. Treatment of DIC was assessed by blood products administered, postpartum hemorrhage management, and laboratory measurements. RESULTS: There were 49 cases of DIC in 151 678 deliveries (3 per 10,000) over the 30 years. Antecedent causes included placental abruption (37%), postpartum hemorrhage or hypovolemia (29%), preeclampsia/HELLP (14%), acute fatty liver (8%), sepsis (6%), and amniotic fluid embolism (6%). The associated maternal morbidity included transfusion ≥ 5 units (59%), hysterectomy (18%), ICU admission (41%), and ATN requiring dialysis (6%). There were three maternal deaths, giving a case fatality rate of 1 in 16. The perinatal outcomes included stillbirth (25%), neonatal death (5%), and NICU admission (72.5%). CONCLUSION: Obstetrical DIC is an uncommon condition associated with high maternal and perinatal morbidity and mortality. Prompt recognition and treatment with timely administration of blood products is crucial in the management of this life-threatening disorder.

Difficult and failed intubation: Incident rates and maternal, obstetrical, and anesthetic predictors.

BACKGROUND: Difficult and failed tracheal intubation may be more common in the obstetrical population. The objective of this study was to determine the incidence of difficult and failed tracheal intubation in a Canadian tertiary care obstetric hospital and to identify predictors. METHODS: Maternal, perinatal, and anesthetic information on all pregnant women or recently pregnant (up to three days postpartum) women undergoing general anesthesia (GA) from 1984 to 2003 at the Izaac Walton Killam Health Centre (IWK) was abstracted from the Nova Scotia Atlee Perinatal Database, and the information was augmented by chart review. The incidence and predictors of difficult and failed tracheal intubation were determined. Analyses using logistic regression were performed for the complete GA cohort and for the subgroup that had Cesarean delivery under GA. RESULTS: There were 102,587 deliveries of ≥20 weeks gestation in the study population, with 3,107 GAs identified, 2,986 records reviewed, and 2,633 GAs (88%) retained in the complete cohort. Difficult tracheal intubation was encountered in 123 of 2,633 (4.7%) women in the complete cohort and 60 of 1,052 (5.7%) women in the Cesarean delivery subgroup. Only two failed tracheal intubations were identified (0.08%) in the complete cohort, and both occurred during GAs for postpartum tubal ligation. The combined rate of difficult/failed tracheal intubation remained stable over the 20 years reviewed despite decreasing GA rates. Amongst the complete cohort, maternal age ≥35 yr, weight at delivery 90 to 99 kg, and absence of labour predicted increased risks; while weight at delivery 90 to 99 kg and absence of labour amongst the Cesarean delivery subgroup predicted difficult/failed tracheal intubation. CONCLUSION: Previously accepted risk factors, such as labour, pre-existing medical conditions and obstetrical disorders, did not predict an increased risk of difficult tracheal intubation, while maternal age ≥35 yr, weight 90 to 99 kg, and absence of active labour were found to predict increased risk.

Contribution of select maternal groups to temporal trends in rates of caesarean section.

OBJECTIVE: To estimate the contribution of select maternal groups to temporal trends in Caesarean section (CS) rates. METHODS: Using the Nova Scotia Atlee Perinatal Database, all deliveries by CS during the 24-year period from 1984 to 2007, at the Women's Hospital, IWK Health Centre were identified. Deliveries by CS were classified into groups using parity (nullipara/multipara), plurality (singleton/multiple), presentation (cephalic/breech/transverse), gestational age (term/preterm), history of previous CS (previous CS/no previous CS), and labour (spontaneous/induced/no labour). CS rates in each group and the contribution of each group to the overall CS rate was determined for three eight-year epochs. The risk of CS in each group over time, accounting for identified maternal, fetal, and obstetric practice factors, was evaluated using logistic regression. RESULTS: Of 113,016 deliveries, 23,232 (20.6%) were identified as deliveries by CS meeting the inclusion and exclusion criteria. The CS rate rose from 16.8% in 1984 to 1991 to 26.8% in 2000 to 2007 (P < 0.001). The biggest contributors to the overall CS rate in the last study epoch (2000-2007) were nulliparous women with singleton, cephalic, term pregnancies with spontaneous or induced labour; women with singleton, cephalic, term pregnancies with previous CS; and women with breech presentation. Adjusted analyses explained some increases in the rate of CS and demonstrated reduced risks in others. CONCLUSION: Only some temporally increased CS rates in select maternal groups remain increased after adjusting for confounding variables. The identification of potentially modifiable maternal risk factors, re-evaluation of the indications and techniques for induction of labour in nulliparous women, provision of clinical services for vaginal birth after Caesarean section, and external cephalic version for selected breech presentation are important clinical management areas to consider for safely lowering the Caesarean section rate.

Outcome of stereotactic radiotherapy for patients with uncontrolled acromegaly.

OBJECTIVE: Linear accelerator based stereotactic radiation therapy (SRT) has been used for the treatment of pituitary tumours; however, little is known concerning the use of this modality for the treatment of patients with acromegaly. We have prospectively studied the short-term outcome of SRT in 12 acromegaly patients who failed to achieve biochemical remission despite surgery and/or pharmacologic therapy. METHODS: We identified all patients who had biochemically uncontrolled acromegaly and were treated with SRT between April 2003 and December 2006. All patients were followed prospectively based on a pre-defined protocol that included Goldman visual field examination, MRI of the sella, and pituitary hormone testing at 3, 6, 12 months, and then yearly. RESULTS: A total of 12 patients with acromegaly were treated with SRT. There were 9 females and the median age of the group was 50 years. The median follow-up was 28.5 months during which time the mean tumor volume decreased by 40%, the median GH fell from 4.1 microg/L to 1.3 microg/L (p = 0.003) and the median IGF-1 dropped more than half from 545.5 microg/L to 260.5 microg/L (p = 0.002). Four patients achieved normal, while an additional 2 achieved near-normal, IGF-1 levels. One patient was able to discontinue and two were able to reduce their acromegaly medications while maintaining a normal IGF-1. A new pituitary hormonal deficit was found at 24 months in one patient who developed hypoadrenalism requiring corticosteroid replacement. CONCLUSION: Based on our early experience, we believe that SRT should be considered in treating patients with uncontrolled acromegaly.

Maternal critical care in obstetrics.

OBJECTIVE: To determine the factors leading to maternal critical care in a tertiary obstetric hospital and the associated trends. METHODS: We conducted a review of the medical records of all women who required transfer for critical care from a free-standing obstetric unit to a general hospital over a 24-year period (1982-2005). RESULTS: During the 24-year period there were five maternal deaths directly associated with 122,001 deliveries (4.1/100,000) and, in addition, 117 women were transferred to the general hospital for critical care (1.0/1000). The death-to-transfer ratio was 1 in 23. Of the women transferred, 93/117 (79.5%) required intensive care and 24/117 (20.5%) needed specialized medical or surgical services not available in the obstetric unit. Of the women transferred, 16/117 (13.7%) were antepartum, and 101/117 (86.3%) were postpartum. Hemorrhage and hypertensive disorders combined to make up 56.4% of all maternal transfers. Women with a multiple pregnancy were more likely to require transfer than those with a singleton pregnancy (RR 3.34; 95% CI 1.4-7.59, P=0.01). CONCLUSION: The majority of maternal transfers for critical care occur postpartum, and in more than half of the cases the reason for transfer is hemorrhage or hypertensive disease. Women with a multiple pregnancy had a significantly greater rate of transfer than those with a singleton, and women with a triplet pregnancy had a greater rate than those with twins. There was a non-significant increase in the number of maternal transfers over the study period.

Maternal and perinatal outcomes with increasing duration of the second stage of labor.

OBJECTIVE: To estimate maternal and perinatal outcomes among women with increasing duration of the second stage of labor. METHODS: A population-based cohort study was conducted among women with low-risk, singleton, vertex, nonanomalous deliveries at or after 37 weeks of gestation between 1988 and 2006. Individual maternal (hemorrhagic, infectious, and traumatic), perinatal (birth depression, infectious, and traumatic), and composite outcomes were evaluated with increasing duration of the second stage. Logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals for all outcomes and to account for confounding variables, including maternal age, prelabor rupture of membranes, augmentation of labor, antibiotics in labor, regional analgesia, gestational age, birth weight, and year of birth. Effect modification caused by method of delivery was considered. RESULTS: From a population of 193,823 women, 121,517 women met inclusion and exclusion criteria, of whom 63,404 (52%) were nulliparous. There was an increase in risk of maternal obstetric trauma, postpartum hemorrhage, puerperal febrile morbidity and composite maternal morbidity, and low 5-minute Apgar score, birth depression, admission to the neonatal intensive care unit, and composite perinatal morbidity among both nulliparous women and multiparous women, with increasing duration of the second stage of labor. Method of delivery only modified the effect of duration of second stage among nulliparous women. CONCLUSION: Risks of both maternal and perinatal adverse outcomes rise with increased duration of the second stage, particularly for duration longer than 3 hours in nulliparous women and longer than 2 hours in multiparous women. LEVEL OF EVIDENCE: II.

Fetal trauma in term pregnancy.

OBJECTIVE: The objective of the study was to determine the incidence and type of fetal trauma in term pregnancy in relation to method of delivery, maternal age, parity, and birthweight. STUDY DESIGN: From the Nova Scotia Atlee Perinatal Database, fetal trauma was evaluated in all term (37 weeks or longer) singleton fetuses without major anomaly in vertex presentation over a 14-year period (1988-2001). RESULTS: The overall risk of fetal trauma was low (2.0%); that of major fetal trauma was 0.16%. Major and minor fetal trauma was significantly increased with labor, compared with no labor (adjusted relative risks [RRs], 9.59; 95% confidence interval [CI], 1.34-68.47, and RR, 11.25; 95% CI, 5.05-25.09, respectively). Cesarean delivery was protective for major and minor fetal trauma, compared with vaginal delivery (adjusted RRs, 0.21; 95% CI, 0.12-0.40, and RR, 0.46; 95% CI, 0.39-0.54, respectively). CONCLUSION: The risk of significant fetal trauma in term pregnancy is very low and most likely to be associated with labor and with assisted vaginal delivery.

A survey of Canadian websites providing information about female urinary incontinence.

OBJECTIVE: Urinary incontinence (UI) is a prevalent health issue that has significant detrimental effects on quality of life. The Internet offers a unique vehicle for incontinent women to access information that could facilitate conservative self-help therapy. An evaluation of Canadian websites offering female UI information was conducted to determine their quality and readability. METHODS: We evaluated websites using published general quality criteria for health sites and a quality assessment tool compiled by the authors for specific UI information derived from published, peer-reviewed clinical practice guidelines. Three health care professionals reviewed sites for quality, Canadian content, and interactivity. The readability of health information was also evaluated. RESULTS: Fifty-six Canadian sites (18 professional, 22 organizational, 16 commercial) were evaluated. Significant agreement was found among the raters' evaluations on all measures. For all sites, the mean scores were general quality, 9/14; specific UI quality, 30/122; reading ease, 37/100; grade level, 10.9. The median score for Canadian content was high, but for interactivity it was low. The only significant difference between site types was for general quality (F [2,165]=3.38, P=0.036). Post hoc Tukey's tests showed a significant difference between organizational and commercial sites, with organizational sites having higher general quality. CONCLUSION: Canadian websites providing female UI information have moderately high general quality, low specific UI information quality, minimal interactivity, and more than minimal Canadian content. The reading level of most sites is too high for average consumers. A webliography of the best sites has been developed to guide patients.

Cumulative economic implications of initial method of delivery.

OBJECTIVE: To examine the cumulative costs of hospital care in the first and subsequent pregnancies associated with different methods in the initial delivery of nulliparous women. METHODS: An 18-year population-based cohort study (1985-2002) using the Nova Scotia Atlee Perinatal Database compared cumulative delivery costs in the first and subsequent pregnancies. Women were identified by initial method of delivery for nulliparous women with singleton cephalic presentation at term undergoing spontaneous or induced labor for planned vaginal delivery, and for nulliparous women undergoing cesarean delivery without labor. Costs that were assessed included nursing hours in antepartum, labor and delivery, postpartum and neonatal intensive care units, physician costs, labor induction agents, consumables, and costs for postpartum hysterectomy, tubal ligation, and dilatation and curettage. RESULTS: A total of 27,613 pregnancies satisfied inclusion and exclusion criteria. When cumulative costs by type of labor at first delivery were considered, induction of labor (7,220 dollars) was more costly than spontaneous onset of labor (6,919 dollars, P = .006). The cumulative costs of assisted vaginal delivery at first delivery (7,288 dollars) and cesarean delivery in labor at first delivery (9,524 dollars) were similar in magnitude and were higher than spontaneous vaginal delivery at first delivery (P < .001). Cesarean delivery in labor in the first delivery was the most costly type of delivery (9,524 dollars), and the differences in cost increased with increasing number of deliveries (P < .05). CONCLUSION: Cesarean delivery in labor in the first delivery is associated with increased cumulative costs compared with other methods of delivery, regardless of the number or type of subsequent deliveries.

Maternal morbidity associated with cesarean delivery without labor compared with induction of labor at term.

OBJECTIVE: To estimate the maternal morbidity associated with cesarean deliveries performed at term without labor compared with morbidity associated with induction of labor at term. METHODS: A 15-year population-based cohort study (1988-2002) using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in nulliparous women delivering by cesarean delivery without labor and nulliparous women at term undergoing induction of labor for planned vaginal delivery with singleton, cephalic presentation. RESULTS: A total of 5,779 pregnancies satisfied inclusion and exclusion criteria, 879 of which were cesarean deliveries without labor. There were no maternal deaths. There was no difference in wound infection, puerperal febrile morbidity, blood transfusion or intraoperative trauma. After controlling for potential confounders, women undergoing cesarean delivery without labor were less likely to have complications of early postpartum hemorrhage (relative risk 0.61, 95% confidence interval 0.42-0.88, number needed to treat 32) and composite maternal morbidity (relative risk 0.71, 95% confidence interval 0.52-0.95, number needed to treat 34) compared with women undergoing induction of labor. Subgroup analyses of maternal outcomes after induction of labor in women by method of delivery were also performed and demonstrated additional risks of traumatic morbidity after induction of labor. The highest morbidity was found in the assisted vaginal delivery and cesarean delivery in labor groups. CONCLUSION: Early postpartum hemorrhage and composite maternal morbidity were decreased in cesarean delivery without labor compared with induction of labor. Hemorrhagic and traumatic morbidities with labor induction are increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.