No. 397 – Conservative Care of Urinary Incontinence in Women

ObjectiveTo outline the evidence for conservative care, including both assessment and management options, for urinary incontinence in women.Intended UsersRelevant primary care providers and medical specialists including but not limited to physicians, nurses, midwives, and pelvic health physiotherapists.Target PopulationWomen (>18 years of age) with urinary incontinence.OptionsAssessment options include gathering of a detailed history, physical examination, laboratory analysis, urodynamic evaluation, and cystoscopy. Conservative management options include lifestyle management, pelvic floor muscle training, behavioural management, and mechanical devices.OutcomesTo provide an evaluation-based summary of current available evidence concerning efficacy of conservative care (assessment and management) strategies for urinary incontinence in women.EvidenceThe Cochrane Library and Medline (2013-2018) were searched to find articles related to conservative care of urinary incontinence in women (>18 years). Articles were appraised, and the collective evidence was graded.Validation MethodsThe evidence obtained was reviewed and evaluated by the Society of Obstetricians and Gynaecologists of Canada (SOGC) Urogynecology Committee under the leadership of the principal authors. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework.Benefits, Harms, and CostsEvidence for the efficacy of conservative care (assessment and management) options for women with urinary incontinence is strong. Furthermore, these options carry minimal or no harm and confer an established cost benefit.Guideline UpdateThis SOGC Clinical Practice Guideline will be automatically reviewed 5 years after publication.SUMMARY STATEMENTS

• 1Assessment – history (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •History alone is not sufficient to diagnose the full spectrum of urinary incontinence. However, a clear history of urinary leakage with physical activity, in the absence of complicated urinary incontinence features, may be sufficient for stress urinary incontinence diagnosis in conjunction with physical examination.
• 2Assessment – physical examination (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •The cough stress test, if positive, is a reliable test to diagnose uncomplicated stress urinary incontinence when complemented by a history consistent with stress urinary incontinence.
  • •Measurement of urethral hypermobility alone has poor reliability and remains controversial in the conservative management of urinary incontinence. However, the presence of an immobile, fixed urethra suggests complex urinary incontinence and may warrant further investigation.
• 3Assessment – urinalysis (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •Urine dipstick testing, microscopic urinalysis and urine culture and sensitivity along with measurement of post-void residual volume when indicated should be performed in all women with urinary incontinence to rule out infections, hematuria, and proteinuria. Further evaluations are indicated when the post-void residual volume is persistently greater than 150 mL.
• 4Assessment – urodynamic studies (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •Urodynamic studies are not indicated in otherwise healthy women with uncomplicated stress urinary incontinence on history and physical examination, as urodynamic study results do not assist with diagnosis or improve treatment outcomes in this group of women. Urodynamic study testing may be warranted in women with complicated urinary incontinence symptoms, urinary incontinence refractory to treatment, or conflicting history and physical examination results.
• 5Assessment – cystoscopy (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •Cystoscopic evaluation of the lower urinary tract may be indicated in women with urge urinary incontinence refractory to treatment, continuous urine leakage suspicious for iatrogenic genitourinary injuries or fistulas, persistent post-void dribbling, and hematuria.
• 6Management – lifestyle (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •Evidence from one randomized controlled trial and one meta-analysis supports lifestyle modification interventions promoting weight loss as a management strategy to reduce urinary incontinence in women who are overweight or obese. A 5% reduction in weight loss has an impact on the reduction of urinary incontinence symptoms. Caffeine reduction demonstrates reduction in symptoms of urgency and frequency.
• 7Management – pelvic floor muscle training (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •Pelvic floor muscle training is an effective therapy for urinary incontinence and can be used alone or as part of a multicomponent therapy that includes lifestyle and behavioural approaches. Progressive programs that are supervised by health care providers are more effective.
• 8Management – adjuncts (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •Although current published studies have limitations, currently there does not appear to be any clear added benefit of using adjunctive therapies (biofeedback, electrical stimulation, or vaginal cones).
• 9Management – behavioural; bladder training (mixed urinary incontinence, urge urinary incontinence):
  • •Scheduled voiding regimens represent an important and effective management strategy as a stand-alone therapy or part of a multicomponent therapy that includes lifestyle and pelvic floor muscle training. Women have been more satisfied with voiding regimens compared with no treatment.
• 10Management – intravaginal mechanical devices (stress urinary incontinence, mixed urinary incontinence):
  • •There is evidence that intravaginal mechanical devices (incontinence pessaries) are effective and may be preferred for women who have incontinence in specific situations such as exercise. Intravaginal mechanical devices may not be as effective as pelvic floor muscle training.

RECOMMENDATIONS

• 1Assessment – history (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •We recommend eliciting a comprehensive voiding, medical, and surgical history in women with urinary incontinence to distinguish those with uncomplicated stress urinary incontinence from other types of urinary incontinence, in order to better assess the need for further physical examinations and investigations prior to treatment planning (strong, low).
• 2Assessment – physical examination (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •We recommend that cough stress test be performed on physical examination to diagnose stress urinary incontinence in conjunction with history taking (strong, low). This cough stress test may have to be done also with reduction of prolapse, if present. While urethral hypermobility may contribute to stress urinary incontinence diagnosis, we recommend against the routine use of Q-tip testing in women with urinary incontinence. The vaginal Q-tip test may be used as an alternative to urethral Q-tip testing in select patients (conditional, moderate).
• 3Assessment – urinalysis (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •We recommend that initial investigations include a urinalysis and, if indicated, urine culture and sensitivity and post-void residual assessment for all women with urinary incontinence. Further evaluations such as a hemoglobin A1c, serum creatinine, and imaging may be considered on a case-by-case basis depending on the results of these initial investigations (strong, moderate).
• 4Assessment – urodynamic studies (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •We recommend that in women with uncomplicated urinary incontinence on history and physical examination, routine urodynamic studies not be undertaken prior to treatment planning (strong, high).
  • •We suggest that urodynamic studies be considered in women with refractory or complicated urinary incontinence symptoms, who have undergone prior incontinence procedures, or with urinary incontinence in the setting of stage 3–4 pelvic organ prolapse (conditional, low).
• 5Assessment – cystoscopy (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •We suggest that cystoscopic evaluation be considered in women with hematuria, or refractory and/or complicated urinary incontinence symptoms (conditional, low).
• 6Management – lifestyle (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •We recommend counselling to support weight loss as a first-line strategy for all women with urinary incontinence who are overweight or obese (strong, high).
  • •We recommend counselling related to reducing caffeine to address symptoms of frequency and urgency (conditional, moderate).
• 7Management – pelvic floor muscle training (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •We recommend pelvic floor muscle training (individually tailored, inclusive of digital pelvic floor muscle examination) to be offered to all women with urinary incontinence (strong, high).
• 8Management – adjuncts (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
  • •We suggest adjunctive pelvic floor muscle therapies be used on an individualized basis only since there is currently no clear added benefit (conditional, moderate).
• 9Management – behavioural; bladder training (mixed urinary incontinence, urge urinary incontinence):
  • •We recommend scheduled toilet regimens to be offered to all women with urge urinary incontinence and mixed urinary incontinence (strong, high).
• 10Management – intravaginal mechanical devices (stress urinary incontinence):
  • •We recommend mechanical devices be used on an individualized basis. We recommend particular consideration of mechanical devices when women have urinary incontinence with high-impact exercises or when there are barriers in accessing supervised pelvic floor muscle training (strong, high).

     

No. 396-Fetal Health Surveillance: Intrapartum Consensus Guideline

ObjectiveTo present evidence and recommendations regarding use, classification, interpretation, response, and documentation of fetal surveillance in the intrapartum period and to provide information to help minimize the risk of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention.Intended UsersMembers of intrapartum care teams, including but not limited to obstetricians, family physicians, midwives and nurses, and their learnersTarget PopulationIntrapartum womenOptionsAll methods of uterine activity assessment and fetal heart rate surveillance were considered in developing this document.OutcomesThe impact, benefits, and risks of different methods of surveillance on the diverse maternal-fetal health conditions have been reviewed based on current evidence and expert opinion. No fetal surveillance method will provide 100% detection of fetal compromise; thus, all FHS methods are viewed as screening tests. As the evidence continues to evolve, caregivers from all disciplines are encouraged to attend evidence-based Canadian educational programs every 2 years.EvidenceLiterature published between January 1976 and February 2019 was reviewed. Medline, the Cochrane Database, and international guidelines were used to search the literature for all studies on intrapartum fetal surveillance.Validation MethodsThe principal and contributing authors agreed to the content and recommendations. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care.Benefits, Harm, and CostsConsistent interdisciplinary use of the guideline, appropriate equipment, and trained professional staff enhances safe intrapartum care. Women and their support person(s) should be informed of the benefits and harms of different methods of fetal health surveillance.RECOMMENDATIONSCommunication

• 1Definitions outlined in this guideline should be adapted into facility policies and fetal health surveillance educational programs for consistency and clarity of terminology and communication (II-3 A).
• 2When communicating with colleagues and documenting fetal surveillance, fetal health surveillance terminology should be used to describe the uterine activity, fetal heart rate, and the classification (III-C).
• 3Communication to the interprofessional team should be done clearly and efficiently (III-C).

Support During Active Labour

• 4Women in active labour should receive continuous close support from an appropriately trained person (I-A).
• 5Fetal surveillance by intermittent auscultation or electronic fetal monitoring requires the presence a professional caregiver (nurse, midwife, and/or physician) with knowledge of fetal surveillance methods, response, and labour support strategies (I-A).
• 6One-to-one care of the woman is recommended, recognizing that the caregivers are really caring for more than 1 patient: the woman and her unborn baby or babies (III-C).

Principles of Intrapartum Fetal Surveillance

• 7The classified intermittent auscultation and electronic fetal monitoring findings must be interpreted in the context of the overall clinical picture (I-A).

Selecting the Method of Fetal Heart Rate Monitoring: Intermittent Auscultation or Electronic Fetal Monitoring

• 8Intermittent auscultation, following an established protocol of surveillance and response, is the recommended method of intrapartum fetal surveillance for healthy women between 37⁰ and 41³ weeks gestation in spontaneous labour, in the absence of risk factors for adverse perinatal and neonatal outcomes (I-B).
• 9Intermittent auscultation may be used for women who are 41⁴ weeks gestation to 42⁰ weeks, provided there is documentation of a normal non-stress test and normal amniotic fluid volume (III-C).
• 10Electronic fetal monitoring is recommended for pregnancies at risk of adverse perinatal outcome (II-A).

Paper Speed

• 11Canadian health care facilities should move towards a universal paper speed of 3 cm/minute for electronic fetal monitoring tracings to facilitate national consistency of practice, education, and research (III-B).

Admission Assessments

• 12Admission intermittent auscultation assessments are recommended for healthy term women presenting in labour, early labour, or query labour in the absence of risk factors for adverse perinatal outcome (I-A).
• 13Admission electronic fetal monitoring assessments are recommended for women with risk factors for adverse perinatal outcome (III-B).
• 14When a woman begins labour following cervical ripening, the method of intrapartum fetal health surveillance monitoring should be determined by the ongoing maternal and fetal risk factors (III-C).

Epidural Analgesia

• 15Intermittent auscultation may continue to be used to monitor the fetus when epidural analgesia is initiated and used during labour in low-risk, term pregnancies in spontaneous labour provided that a protocol is in place for frequent intermittent auscultation assessment (III-C).
• 16Electronic fetal monitoring is recommended for combined spinal–epidural analgesia (CSE) because CSE is associated with a higher risk of an atypical or abnormal fetal heart pattern than with the use of epidural alone (1-B).

Intermittent Auscultation in Labour

• 17After establishing the baseline fetal heart rate, fetal heart rate assessments should be conducted by listening and counting immediately after the contraction for 30–60 seconds to ensure that the fetal heart rate is consistent with the established fetal baseline rate and to detect accelerations or decelerations from baseline (II-3 B).
• 18When using intermittent auscultation, if a deceleration is heard or suspected immediately following a contraction, further assessment is required by changing position and listening again or by initiating EFM. If decelerations are confirmed by the further IA, EFM is indicated. Intrauterine resuscitation should be initiated as required (III-C).
• 19When electronic fetal monitoring is initiated in response to abnormal intermittent auscultation, it may be removed when no maternal fetal risk factors are identified based on a review of the overall clinical picture and a normal tracing is observed; a minimum of 20 minutes of electronic fetal monitoring tracing is suggested (III-C).

Electronic Fetal Monitoring in Labour

• 20When a normal tracing is identified during first stage of labour, it may be appropriate to interrupt the electronic fetal monitoring tracing for up to 30 minutes to facilitate periods of ambulation, hydrotherapy, or position change, providing that (1) the maternal-fetal condition is stable and (2) if oxytocin is being administered, the infusion rate is stable (III-B).
• 21Electronic fetal monitoring is best interpreted with a continuous tracing of the uterine activity and fetal heart rate. If a continuous tracing is not possible, or there is uncertainty of interpretation due to the quality of the tracing, use of an intrauterine pressure catheter and/or fetal spiral electrode could be considered, if available (III-B).

Classification of Intrapartum Fetal Surveillance

• 22The terms normal and abnormal are used to classify intermittent auscultation (III-C).
• 23The presence of uterine tachysystole during IA classifies intermittent auscultation fetal health surveillance assessment as abnormal, and electronic fetal monitoring should be initiated (III-C).
• 24The terms normal, atypical, and abnormal are used to classify electronic fetal monitoring (III-C).

Maternal Heart Rate

• 25Assess and document the maternal heart rate concurrently with the fetal heart rate, when using either IA or EFM, to differentiate maternal from fetal heart rate:
  • aAt initial assessment when determining baseline fetal heart rate
  • bAt any time when there is uncertainty between the maternal heart rate and fetal heart rate
  • cBased on the stage of labour:
    • iIn the active first stage and passive second stage of labour: every 4 hours with intact membranes
    • iiIn the active first stage and passive second stage of labour: every 2 hours with ruptured membranes
    • iiiIn the active second stage of labour: every 15–30 minutes (III-C)

Fetal Health Surveillance Assessment in the Active Second Stage of Labour

• 26Intermittent auscultation is recommended if the woman continues to meet the criteria for intermittent auscultation assessments (IB).
• 27Electronic fetal monitoring should be used for pregnancies at risk of adverse perinatal outcomes (IIA).

Intrauterine Resuscitation

• 28Maternal vital signs should be obtained as part of intrauterine resuscitation (III-C).
• 29Maternal oxygen should be administered for confirmed maternal hypoxia or hypovolemia, and NOT routinely used as a resuscitative measure for atypical or abnormal fetal heart tracings (1-A).
• 30An intravenous bolus should be used only in the event of maternal hypovolemia and/or hypotension (III-C).

Digital Fetal Scalp Stimulation

• 31Digital fetal scalp stimulation is recommended as an indirect assessment of acid-base status in response to atypical or abnormal electronic fetal monitoring tracings (II-B).
• 32The absence of an acceleration with digital fetal scalp stimulation does not necessarily indicate fetal compromise. When acceleration does not occur:
• •Fetal scalp blood sampling should be considered when available (II-B).
• •If fetal scalp blood sampling is not possible, consider ongoing vigilant evaluation of the fetal health surveillance tracing if other elements of the fetal health surveillance and the clinical situation are normal or prompt delivery depending on the overall clinical situation (III-C).

Fetal Scalp Blood Sampling

• 33Where facilities and expertise exist, fetal scalp blood sampling for assessment of fetal acid-base status (using lactate or pH) is recommended in women at gestations >34 weeks when delivery is not imminent and when
  • aatypical/abnormal electronic fetal monitoring tracings are identified and not resolved with intrauterine resuscitation measures (III-C);
  • bdigital fetal scalp stimulation does not result in an acceleratory fetal heart rate response (III-C).
• 34Fetal scalp lactate blood sampling is a reliable tool to assess intrapartum fetal acidosis and may be used when clinically indicated, available, and with resources to respond (I-A).

Umbilical Cord Blood Gases

• 35Cord blood sampling of both umbilical arterial and umbilical venous blood is recommended for ALL births (III-C).

Documentation

• 36Fetal health surveillance terminology should be used to describe the uterine activity, fetal heart rate and the classification in documentation (III-A).
• 37Classification should be included whenever fetal health surveillance is documented (III-A).
• 38Recommended criteria for frequency of assessment, classification, and documentation vary based on the stage of labour, maternal fetal status, and method of fetal surveillance (III-B).

Fetal Surveillance Technology Not Recommended

• 39Fetal pulse oximetry, with or without electronic fetal surveillance, is not recommended (III-C).
• 40ST waveform analysis for the intrapartum assessment of the compromised fetus is not recommended (I-A).
• 41Computer-based interpretation of electronic fetal monitoring tracing is not recommended (I-D).

Fetal Health Surveillance Education

• 42All providers of intrapartum obstetrical care (physicians, nurses, midwives) should be required to commit to formal education in fetal health surveillance and maintain up-to-date competence with formal education review of both intermittent auscultation and electronic fetal monitoring every 2 years (II-B).
• 43Each facility should provide opportunities for all intrapartum care providers (physicians, nurses, midwives) to regularly attend an interdisciplinary educational discussion of fetal health surveillance clinical situations, including both intermittent auscultation and electronic fetal monitoring, to ensure common terminology and shared understanding and to foster the concept of team responsibility (III-C).

     

Technical Update No. 352: The Role of Early Comprehensive Fetal Anatomy Ultrasound Examination

Tweetable AbstractMost detectable fetal anomalies are present in early pregnancy. Early fetal anatomy at 13-16 weeks, performed by trained operator, should be considered for women at high risk for fetal anomalies or when the routine mid-trimester anatomy scan may be technically challenging.SUMMARY STATEMENTS

• 1.Development of fetal organs begins early in the first trimester, with the majority of organs visible by ultrasound evaluation towards the end of the first trimester of pregnancy (high).
• 2.The majority of significant and sonographically detectable fetal anomalies can be detected on early fetal anatomic ultrasound assessment (high).
• 3.Early detection of fetal anomalies allows patients to obtain counselling consultations, and genetic testing at an earlier gestational age, as well as more time to consider options for pregnancy management (high).

RECOMMENDATIONS

• 1.Medical personnel (physicians, technologists, or ultrasound practitioners) who have substantial experience or training in the assessment and interpretation of early comprehensive fetal anatomic scanning should be performing the examination (strong, high).
• 2.The examination can be performed transvaginally, transabdominally, or by both approaches, and the choice for each mode depends on the fetal position, the gestational age, and the experience of the operator (strong, high).
• 3.Early comprehensive fetal anatomic scanning at 13–16 weeks’ gestation should be considered for women who have higher risk for significant fetal anomalies or in whom it is anticipated that a midtrimester transabdominal scan will be technically challenging (strong, high). This scan does not replace the routine 18- to 22-week anatomy scan.

     

Guideline No. 422d: Menopause and Sexuality

ObjectiveProvide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.Target PopulationPerimenopausal and postmenopausal women.Benefits, Harms, and CostsTarget population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.EvidenceDatabases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended Audiencephysicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.SUMMARY STATEMENTS

• 1Low sexual desire in combination with distress is most common in women in mid-life (high).
• 2Vaginal atrophy is a common cause of sexual pain in menopausal women (high).
• 3Sexual dysfunction in menopausal women can be categorized as disorders involving desire, arousal, pain, and orgasm. These categories often overlap (high).
• 4A brief sexual history is part of the evaluation of menopausal women (moderate).
• 5The treatment of sexual dysfunctions involves a multifaceted approach that addresses medical, psychological, and relationship issues (high).
• 6Local estrogen therapy treats genitourinary syndrome of menopause (high).
• 7Pelvic physiotherapy is an excellent adjuvant treatment for hypercontracted pelvic floor muscles (often referred to as vaginismus) and genito-pelvic pain (low).
• 8Flibanserin has been shown to improve desire in women (moderate).
• 9Transdermal testosterone has been shown to increase desire, arousal, and satisfying sexual events, and to decrease personal distress (high).
• 10Psychological therapies, including cognitive behavioural therapy, mindfulness-based therapy, couples’ therapy, and sexual therapies, are useful for treating sexual dysfunctions (moderate).
• 11Sexual dysfunction is common in patients with depression, those on selective serotonin reuptake inhibitors (SSRIs), women with primary ovarian insufficiency, and those with a history of breast cancer (high).

RECOMMENDATIONS

• 1The patient's problem should be categorized as related to desire, arousal, pain, or orgasm, in order to facilitate treatment and to triage care (strong, moderate).
• 2Health care providers should include a sexual screening history and physical examination in the initial evaluation of menopausal women (strong, low).
• 3Vaginal estrogens, lubricants and moisturizers, vaginal dehydroepiandrosterone, and ospemifene may be used as treatments for vaginal atrophy related to menopause (strong, high).
• 4For postmenopausal women with hypoactive sexual desire disorder, the best current options include managing pain, addressing any biopsychological factors, counselling, and prescribing transdermal testosterone (off-label) or flibanserin (strong, moderate).
• 5Patients with breast cancer and symptomatic genitourinary syndrome of menopause can be offered local vaginal estrogen if local lubricants and moisturizers are ineffective, after consulting with the patient's oncologist (conditional, moderate).

     

Guideline No. 393-Diabetes in Pregnancy

ObjectivesThis guideline reviews the evidence relating to the diagnosis and obstetrical management of diabetes in pregnancy.OutcomesThe outcomes evaluated were short and long-term maternal outcomes including pre-eclampsia, Caesarean section, future diabetes and other cardiovascular complications; and fetal outcomes including congenital anomalies, stillbirth, macrosomia, birth trauma, hypoglycemia and long-term effects.EvidencePublished literature was retrieved through searches of PubMed and The Cochrane Library using appropriate controlled vocabulary (MeSH terms “diabetes” and “pregnancy”). Where appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials.ValuesThe quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.Summary Statements

• 1The adverse outcomes associated with diabetes in pregnancy are substantially associated with hyperglycemia as well as the co-existing metabolic environment. Women with pre-existing diabetes should receive preconception care to optimize blood sugar control and other co-morbidities. Outcomes for the fetus/neonate and the mother in both pre-gestational diabetes mellitus and gestational diabetes mellitus pregnancies are improved by multidisciplinary management whose goal is achieving optimal blood sugar control and appropriate fetal surveillance (II-2).
• 2Retrospective studies indicate that women with pre-gestational diabetes mellitus have an increased risk of stillbirth before 40 weeks of gestation when compared with the general obstetrical population. Similarly, large recent cohort and simulation studies of women with gestational diabetes mellitus pregnancies also indicate a higher risk of stillbirth between 36-39 weeks gestation (II-2).
• 3Women with gestational diabetes mellitus have a higher risk of pre-eclampsia, shoulder dystocia, Caesarean section and large for gestational age infants (II-2).
• 4Treatment of women with gestational diabetes mellitus and optimization of glycemic control reduces the risk of pre-eclampsia, shoulder dystocia, and large for gestational age infants (I).
• 5The occurrence of gestational diabetes mellitus increases the risk of developing type 2 diabetes in the future for the mother (II-2).

Recommendations 

• 1The “preferred screening and diagnostic 2-step” approach for gestational diabetes mellitus from Diabetes Canada's 2018 guidelines is endorsed. All pregnant women should be offered screening between 24-28 weeks using a standardized non-fasting 50-g glucose challenge screening test (GCT) with plasma glucose (PG) measured 1 hour later (III-B).
  • 1.1If the value is <7.8 mmol/L, no further testing is required.
  • 1.2If the value of the GCT is 7.8–11.0, a 2-hour 75-g oral glucose tolerance test with fasting PG (FPG), 1-hour PG, 2-hour PG should be performed.Gestational diabetes mellitus is diagnosed if 1 value is met or exceeded:
    • iFPG ≥5.3 mmol/L
    • ii1-h PG ≥10.6 mmol/L
    • iii2-h PG ≥9.0 mmol/L
  • 1.3If the value of the GCT is ≥11.1 mmol/L, gestational diabetes mellitus is diagnosed
• 2The “alternative 1-step diagnostic” approach from Diabetes Canada's 2018 guidelines is acceptable. In this strategy pregnant women should be offered testing between 24-28 weeks using a standardized 2-hour 75-g oral glucose tolerance test with fasting plasma glucose (FPG), 1-hour plasma glucose (PG), 2-hour PG (III-B).Gestational diabetes mellitus is diagnosed if 1 value is met or exceeded:
  • iFPG ≥5.1 mmol/L
  • ii1-h PG ≥10.0 mmol/L
  • iii2-h PG ≥8.5 mmol/L
  It is recognized that the use of different diagnostic thresholds for the “preferred” and “alternate” strategies could cause confusion in certain settings. Despite this the committee has identified the importance of remaining aligned with the current Diabetes Canada guidelines as being a priority. It is thus recommended that each care centre strategically align with one of the two strategies and implement protocols to ensure consistent and uniform reporting of test results.
• 3If there is a high risk of gestational diabetes mellitus based on multiple risk factors, screening or testing should be offered during the first half of the pregnancy and repeated at 24-28 weeks gestation if initially normal. If for any reason it was missed or if there is a clinical suspicion of later onset gestational diabetes, a screening or diagnostic test should be performed (II-2B).
• 4Women with pre-existing or gestational diabetes mellitus should be provided with care by a multidisciplinary team aimed at attaining and then maintaining euglycemia (II-2B).
• 5For patients with pre-gestational diabetes mellitus or gestational diabetes mellitus, starting at 28 weeks as a baseline, with subsequent serial assessment of fetal growth every 3-4 weeks is suggested to assess the effect of maternal glycemic control on fetal growth rate and amniotic fluid volume (II-2B).
• 6Initiation of weekly assessment of fetal well-being at 36 weeks is recommended in pre-gestational diabetes mellitus and in gestational diabetes mellitus. It is also reasonable to consider weekly fetal assessment for women with diet controlled gestational diabetes mellitus beginning at 36 weeks. Acceptable methods of assessment of fetal well-being near term can include the non-stress test, non-stress test + amniotic fluid index, biophysical profile or a combination of the above (III-A).
• 7If co-morbid factors are present such as obesity, evidence of suboptimal glycemic control, large for gestational age (>90%), previous stillbirth, hypertension or small for gestational age (<10%) are present, earlier onset and/or more frequent fetal health surveillance is recommended. In specific cases where fetal growth restriction is suspected, the addition of umbilical artery and fetal middle cerebral artery Doppler assessment may be helpful (II-2A).
• 8Pregnant women with gestational diabetes mellitus or with pre-gestational diabetes mellitus should be offered induction between 38-40 weeks of gestation depending on their glycemic control and other co-morbidity factors (II2-B).
• 9Antenatal corticosteroid therapy should be administered to women with insulin-treated gestational diabetes mellitus and pregestational diabetic women at the same dosage, according to the same indications, and in the same gestational age range as that recommended for non-diabetic women (Skoll A, et al. No. 364-Antenatal Corticosteroid Therapy for Improving Neonatal Outcomes. J Obstet Gynaecol Can 2018;40:1219-39). When administered to women with preexisting or poorly controlled diabetes, close maternal glycemic surveillance is recommended (III-B). Following the first dose of betamethasone, the following insulin adjustments are recommended as per Diabetes Canada guidelines (Diabetes Canada Clinical Practice Guidelines Expert C, et al. Diabetes and Pregnancy. Can J Diabetes 2018;42 Suppl 1:S255-S82):
  • •Day 1: Increase the night insulin dose by 25%
  • •Days 2 and 3: Increase all insulin doses by 40%
  • •Day 4: Increase all insulin doses by 20%
  • •Day 5: Increase all insulin doses by 10% to 20%
  • •Days 6 and 7: Gradually taper insulin doses to pre-betamethasone doses
• 10If not previously done, in women with threatened preterm labour requiring betamethasone, a screening and diagnostic test for gestational diabetes mellitus should be performed either before or at least 7 days after the administration of betamethasone (III-B).
• 11Women with GDM should be offered testing with a 75-g oral glucose tolerance test between 6 weeks and 6 months postpartum to detect prediabetes and diabetes (Diabetes Canada Clinical Practice Guidelines Expert C, et al. Diabetes and Pregnancy. Can J Diabetes 2018;42 Suppl 1:S255-S82) (II-2A).
  • 11.1 Normal
    • iFasting plasma glucose (FPG) <6.1 mmol/L
    • ii2h <7.8 mmol/L
    • iiiHbA_1C <6.0%
  • 11.2 Pre-diabetic
    • iFPG 6.1-6.9 mmol/L or
    • ii2h plasma glucose (PG) 7.8-11.0 mmol/L or
    • iiiHbA_1C 6.0-6.4%
  • 11.3 Type 2 Diabetes mellitus
    • iFPG ≥ 7.0 mmol/L
    • iiRandom PG or 2h PG ≥11.1 mmol/L
    • iiiHbA_1C ≥6.5%
• 12Breastfeeding is strongly recommended after delivery for all women with pre-gestational diabetes mellitus or gestational diabetes mellitus (II-2A).

     

Guideline No. 422f: Menopause and Breast Cancer

ObjectiveProvide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.Target PopulationPerimenopausal and postmenopausal women.Benefits, Harms, and CostsTarget population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.EvidenceDatabases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended Audiencephysicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.SUMMARY STATEMENTS

• 1The association between breast cancer risk and menopausal hormone treatment is complex (moderate).
• 2Systemic menopausal hormone therapy is contraindicated in women with a personal history of any type of breast cancer (high).
• 3Non-hormonal options for systemic symptom management can be used in women who have had breast cancer (high).
• 4Menopausal hormone therapy does not significantly increase breast cancer risk in premenopausal BRCA carriers who have had risk-reducing salpingo-oophorectomy (moderate).
• 5Menopausal hormone therapy does not appear to increase breast cancer risk in unaffected BRCA1 or BRCA2 mutation carriers (moderate).

RECOMMENDATIONS

• 1When indicated, prescribe the menopausal hormone therapy regimen that confers the lowest possible breast cancer risk (conditional, moderate).
• 2Modifiable risk factors, such as weight, smoking, alcohol use, and exercise, should be optimized among menopausal patients considering treatment (strong, high).
• 3Non-pharmacotherapeutic options for the management of vasomotor symptoms in breast cancer patients include paced breathing, acupuncture, and cognitive behavioural therapy (strong, moderate).
• 4Venlafaxine is the first-line non-hormonal alternative for the management of vasomotor symptoms in breast cancer patients (conditional, moderate).
• 5Paroxetine, gabapentin, oxybutynin, and clonidine are non-hormonal options for refractory vasomotor symptoms. Paroxetine should be used with caution in patients receiving tamoxifen (conditional, moderate).
• 6Non-hormonal options for the management of genitourinary syndrome of menopause in breast cancer survivors include vaginal moisturizers, lubricants for intercourse, pelvic floor physiotherapy, and dilators or vibrators (strong, moderate).
• 7Local vaginal estrogens can be considered in breast cancer survivors. Clinical trials are ongoing to establish safety of vaginal hormonal products in breast cancer survivors taking aromatase inhibitors (conditional, moderate).
• 8Vaginal dehydroepiandrosterone and oral ospemifene are alternatives to local estrogen treatment for genitourinary syndrome of menopause; however, further studies are needed in breast cancer survivors (conditional, low).
• 9Menopausal hormone therapy regimens should be individualized and preference given to estrogen-alone therapy in any patient who has undergone hysterectomy (conditional, high).

     

Guideline No. 422b: Menopause and Genitourinary Health

ObjectiveProvide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.Target PopulationPerimenopausal and postmenopausal women.Benefits, Harms, and CostsTarget population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.EvidenceDatabases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended Audiencephysicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.SUMMARY STATEMENTS

• 1The effects of estrogen deficiency on urogenital tissues include signs and symptoms of vulvovaginal atrophy, urinary urgency, dysuria, and recurrent urinary tract infection (high).
• 2Genitourinary syndrome of menopause is common and impairs quality of life, sexual function, and partner relationships (high).
• 3Without treatment, this syndrome will evolve chronically in most women and progress to functional and structural urogenital tissue changes that can be difficult to reverse even with treatment (high).

RECOMMENDATIONS

• 1Women entering menopause should be educated about the progressive impact of estrogen deficiency on urogenital health and the many options available for symptom relief (strong, high).
• 2Menopausal women should be comprehensively screened for genitourinary syndrome of menopause symptoms on an ongoing basis, as symptoms can present insidiously and become bothersome long after the menopausal transition (strong, high).
• 3First-line management options for genitourinary syndrome of menopause may include vaginal lubricants and/or vaginal moisturizers, particularly if patient concerns are limited to vaginal dryness or dyspareunia (strong, high).
• 4Second-line therapy for genitourinary syndrome of menopause is vaginal estrogen, administered either as a cream, tablet, or sustained-release ring (strong, high). Clinically significant systemic hormone absorption does not occur with low-dose therapy, so concomitant progestogen therapy is not needed (strong, high).
• 5Other second-line pharmacotherapy for atrophic vaginal symptoms includes the oral selective estrogen receptor modulator, ospemifene, and vaginal dehydroepiandrosterone ovules (strong, high).
• 6Long-term use of intravaginal laser therapy to manage genitourinary syndrome of menopause or stress urinary incontinence remains experimental and should be conducted only within the protocols of well-executed clinical trials designed to establish its safety and efficacy (strong, very low).

     

Guideline No. 422e: Menopause and Cardiovascular Disease

ObjectiveProvide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.Target PopulationPerimenopausal and postmenopausal women.Benefits, Harms, and CostsTarget population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.EvidenceDatabases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended Audiencephysicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.SUMMARY STATEMENTS

• 1Women who initiate menopausal hormone therapy shortly after menopause are, in general, at low risk for events in the next few years (high). Evidence supports aggressive identification and modification of risk factors as the most effective means of reducing cardiovascular risk (high).
• 2Women who initiate menopausal hormone therapy 10 or more years after menopause are at increased risk for adverse cardiac events (high).
• 3With respect to stroke, increased risk has been identified in all age groups using standard formulations of menopausal hormone therapy; however, the incidence in young women is extremely low (low).
• 4Incidence of venous thrombotic events increase with age (> 60 y) and BMI, even in otherwise healthy women; menopausal hormone therapy increases the risk (high).
• 5Menopausal hormone therapy is not indicated for primary or secondary prevention of cardiovascular disease (moderate).
• 6Women with premature or early-onset menopause appear to be at an increased risk of adverse cardiovascular outcomes, and this risk may be prevented by the use of menopausal hormone therapy until the average age of menopause (moderate).
• 7Menopausal hormone therapy increases the risk of venous thromboembolism; oral and combined hormone therapy preparations are more closely associated with risk of venous thromboembolism than either with transdermal preparations or estrogen alone (moderate).
• 8There is a lack of high-quality data to provide guidance on the impact of routes of estrogen administration on the risk of venous thrombotic events or cardiovascular disease (low).

RECOMMENDATIONS

• 1Menopausal hormone therapy should be offered as the most effective treatment for the relief of menopausal symptoms (strong, high).
• 2When prescribing menopausal hormone therapy, the lowest effective dose of estrogen, and, where indicated, estrogen-only therapy, should be offered to minimize the associated risk of venous thromboembolism (conditional, low).
• 3The lowest effective dose of estrogen, either oral or transdermal, should be prescribed to minimize the risk of stroke (conditional, low).
• 4When prescribing combined hormone therapy, choice of progestogen should favour those least likely to affect markers for cardiovascular disease. (strong, moderate).
• 5A tissue selective estrogen complex may be used without a progestin to provide menopausal hormone therapy and uterine protection for relief of early menopausal symptoms (conditional, moderate). To date, these agents do not appear to be associated with cardiovascular risk.

     

Guideline No. 422c: Menopause: Mood,Sleep, and Cognition

ObjectiveProvide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.Target PopulationPerimenopausal and postmenopausal women.Benefits, Harms, and CostsTarget population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.EvidenceDatabases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended Audiencephysicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.SUMMARY STATEMENTS

• 1The perimenopausal period is a window of vulnerability for the development of depressive symptoms and major depressive episodes, even in women with no history of depression (high).
• 2Factors related and unrelated to menopause contribute to the occurrence and severity of mood symptoms in mid-life. Factors related to menopause are those that are context-related or timing-related, such as vasomotor symptoms, sleep disturbances, and health problems, whereas those unrelated to menopause represent a continuum of risk that precedes menopause, or longitudinal risk factors, such as unemployment, smoking, and lifetime history of anxiety (high).
• 3Recent large-scale studies show an elevated risk of depression in women following hysterectomy, with or without oophorectomy. A history of primary ovarian insufficiency, which occurs in 1% of women, is also associated with an increased risk of depression (high).
• 4Poor sleep quality, as measured both subjectively and objectively, is common among women in the perimenopausal and postmenopausal periods (high).
• 5Cognitive symptoms, such as worsening memory and slower cognitive speed, are often reported among newly menopausal women, and these symptoms have been demonstrated in prospective, longitudinal studies (moderate).

RECOMMENDATIONS

• 1Proven therapeutic options for depression at any life stage (i.e., antidepressants, cognitive behavioural therapy, and other behaviour-based psychotherapies) should remain the first-line treatment options for depressive symptoms and episodes during the menopausal transition and postmenopausal years (strong, high).
• 2For women experiencing recurrent episodes of depression during the perimenopausal period, selection of antidepressants should consider the patient's response to and toleration of previous trials of antidepressants (strong, moderate).
• 3For women experiencing new-onset depression, both adverse effects (e.g., sexual dysfunction, weight changes) and drug–drug interactions (e.g., between specific selective serotonin reuptake inhibitors and tamoxifen) specific to this population should be considered (strong, moderate).
• 4There is some evidence that hormone therapy has antidepressant effects similar in magnitude to those observed with classic antidepressant agents in perimenopausal women with depression, with or without concomitant vasomotor symptoms (strong, high). However, hormone therapy is ineffective in treating depressive disorders in postmenopausal women, suggesting a possible window of opportunity for the antidepressant benefits of hormone therapy in perimenopause (strong, moderate).
• 5The approach to poor sleep during the menopausal transition should initially include education about sleep hygiene, and primary sleep disorders should be ruled out (strong, high).
• 6Vasomotor symptoms are a significant contributor to sleep disruption and should be addressed; hormone therapy may improve sleep when vasomotor symptoms are present (strong, high).
• 7Several other therapies for sleep have shown benefit, including cognitive behavioural therapy–insomnia (strong, high), aerobic exercise, eszopiclone, venlafaxine, black cohosh, and valerian root (strong, moderate).
• 8For women with cognitive complaints, lifestyle modifications are recommended to decrease the risk of cognitive decline. These include increasing aerobic exercise and including vegetables in the diet more often, as well as limiting the potential influence of hypertension, diabetes, and atherosclerotic disease (strong, high).
• 9Menopausal hormone therapy has not been shown to significantly improve measures of cognitive function over several years of use (strong, moderate).

     

Guideline No. 439: Diagnosis and Management of Vasa Previa

ObjectiveTo summarize the current evidence and to make recommendations for diagnosis and classification of vasa previa and for management of women with this diagnosis.Target populationPregnant women with vasa previa or low-lying fetal vessels.OptionsTo manage vasa previa in hospital or at home, and to perform a cesarean delivery preterm or at term, or to allow a trial of labour when a diagnosis of vasa previa or low-lying fetal vessels is suspected or confirmed.OutcomesProlonged hospitalization, preterm birth, rate of cesarean delivery, and neonatal morbidity and mortality.Benefits, harms, and costsWomen with vasa previa or low-lying fetal vessels are at an increased risk of maternal and fetal or postnatal adverse outcomes. These outcomes include a potentially incorrect diagnosis, need for hospitalization, unnecessary restriction of activities, an early delivery, and an unnecessary cesarean delivery. Optimization of diagnostic and management protocols can improve maternal and fetal or postnatal outcomes.EvidenceMedline, Pubmed, Embase, and the Cochrane Library were searched from inception to March 2022, using medical subject headings (MeSH) and keywords related to pregnancy, vasa previa, low-lying fetal vessels, antepartum hemorrhage, short cervix, preterm labour, and cesarean delivery. This document presents an abstraction of the evidence rather than a methodological review.Validation methodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended audienceObstetric care providers, including obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, and radiologists.Tweetable AbstractUnprotected fetal vessels in placental membranes and cord that are close to the cervix, including vasa previa, need careful characterization by sonographic examination and evidence-based management to reduce risks to the baby and the mother during pregnancy and delivery.SUMMARY STATEMENTS

• 1.A marginal sinus or a loop of cord above the cervix are frequent causes of an incorrect diagnosis of vasa previa (low).
• 2.Depending on gestational age when vasa previa or low-lying fetal vessels are diagnosed, these conditions will resolve closer to the time of delivery in a large proportion of women (moderate).
• 3.Most women with vasa previa have an associated risk factor (moderate).
• 4.Depending on individual patient factors, vasa previa can be safely managed on an outpatient basis in many women (moderate).
• 5.Bed rest or reduced activity does not improve outcomes in women with vasa previa and can be harmful. However, sexual intercourse/insertion of foreign bodies in vagina or rectum have potential for harm, particularly in the third trimester (low).

RECOMMENDATIONS

• 1.The physician interpreting an obstetric sonographic examination should classify fetal vessels <2 cm from the cervical os as vasa previa (strong, moderate).
• 2.The physician interpreting an obstetric sonographic examination should classify vessels between 2 and 5 cm from the cervical os as low-lying fetal vessels (conditional, low).
• 3.The obstetric sonographic provider should use transvaginal sonography with colour mapping and pulsed-wave Doppler to diagnose vasa previa or other related variants (strong, moderate).
• 4.When a diagnosis of vasa previa or low-lying fetal vessels is made remote from delivery, the obstetric care provider should confirm the diagnosis closer to the time of delivery (strong, moderate).
• 5.The obstetric sonographic provider should assess the placental cord insertion site in all women at the routine second trimester fetal anatomical scan (conditional, moderate).
• 6.The physician interpreting an obstetric sonographic examination should not diagnose an abnormality of placental morphology, location, placental cord insertion, or vasa previa before the routine second trimester obstetrical sonographic scan (conditional, moderate).
• 7.The obstetric sonographic provider should perform targeted screening for vasa previa in all women with a risk factor (strong, moderate).
• 8.The obstetric care provider should consider hospitalization in women with vasa previa at 32 weeks of gestation, and in women with additional risk factors for early delivery, such as multiple gestation or a short cervix, before 32 weeks (conditional, moderate).
• 9.In women with vasa previa and a singleton pregnancy, the obstetric care provider should perform a cesarean delivery at 35⁰ to 35⁶ weeks. They should consider an earlier delivery if there are additional risk factors for preterm delivery (strong, moderate).
• 10.In women with vasa previa and a twin pregnancy, the obstetric care provider should consider a cesarean delivery at 33⁰ to 34⁶ weeks for dichorionic twins and at 32⁰ to 33⁶ weeks for monochorionic twins. They should consider an earlier delivery if there are additional risk factors for preterm delivery, such as higher-order multiple pregnancy or a short cervix (conditional, low).
• 11.In women with low-lying fetal vessels, the obstetric care provider should consider a cesarean delivery at 37⁰ to 38⁶ weeks for a singleton pregnancy and at 36⁰ to 37⁶ weeks for dichorionic twins (conditional, low).
• 12.In women with vasa previa, the obstetric care provider should consider timely access to an operating room, an obstetrician, an anesthetist, and an appropriate neonatal intensive care unit when deciding location of admission for observation or delivery (conditional, low).

     

Guideline No. 441: Antenatal Fetal Health Surveillance

ObjectiveTo summarize the current evidence and to make recommendations for antenatal fetal health surveillance (FHS) to detect perinatal risk factors and potential fetal decompensation in the antenatal period and to allow for timely intervention to prevent perinatal morbidity and/or mortality.Target populationPregnant individuals with or without maternal, fetal, or pregnancy-associated perinatal risk factors for antenatal fetal decompensation.OptionsTo use basic and/or advanced antenatal testing modalities, based on risk factors for potential fetal decompensation.OutcomesEarly identification of potential fetal decompensation allows for interventions that may support fetal adaptation to maintain well-being or expedite delivery.Benefits, harms, and costsAntenatal FHS in pregnant individuals with identified perinatal risk factors may reduce the chance of adverse outcomes. Given the high false-positive rate, FHS may increase unnecessary interventions, which may result in harm, including parental anxiety, premature or operative birth, and increased use of health care resources. Optimization of surveillance protocols based on evidence-informed practice may improve perinatal outcomes and reduce harm.EvidenceMedline, PubMed, Embase, and the Cochrane Library were searched from inception to January 2022, using medical subject headings (MeSH) and key words related to pregnancy, fetal monitoring, fetal movement, stillbirth, pregnancy complications, and fetal sonography. This document represents an abstraction of the evidence rather than a methodological review.Validation methodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended audienceAll health care team members who provide care for or education to obstetrical patients, including maternal fetal medicine specialists, obstetricians, family physicians, midwives, nurses, nurse practitioners, and radiologists.SUMMARY STATEMENTS

• 1.Accurate and ongoing early identification of risk factors for potential fetal decompensation allows care providers to develop an individualized care plan to optimize fetal well-being (moderate).
• 2.The nonstress test (NST) may be used in conjunction with a review of the total clinical picture to assess fetal well-being. An NST should be used only in the presence of a clear indication or finding associated with increased risk of fetal hypoxemia (moderate).
• 3.Sonography can evaluate amniotic fluid, estimated fetal weight, biophysical profile/modified biophysical profile, and Doppler blood flows to provide information regarding fetal well-being in pregnancies at risk of fetal morbidity (moderate).
• 4.Interprofessional team communication and documentation should be clear, using accepted and defined terminology (high).

RECOMMENDATIONS

• 1.Care providers should review and document perinatal risk factors (prior pregnancy, fetal, maternal, familial) at the initial visit and update factors throughout pregnancy (strong, moderate).
• 2.Pregnant individuals should be advised of local resources and/or the need for transfer of care based on pregnancy risk factors (strong, moderate).
• 3.Regular prenatal visits should include assessment and documentation of the presence of fetal heart tones, uterine size, pregnancy concerns or risk factors, the plan of care, and the discussion with the pregnant individual (strong, moderate).
• 4.All pregnant individuals should be advised to regularly monitor fetal movements starting at 26 weeks gestation (conditional, low).
• 5.If a reduction of fetal movements is identified, regardless of the technique used to assess fetal movements, pregnant individuals should be advised to present to their care provider or local obstetrical unit immediately for further evaluation (strong, low).
• 6.The nonstress test (NST) should be administered and interpreted by appropriately trained health professionals (strong, high).
• 7.A ≥2 cm × 1 cm pocket of fluid by transabdominal sonography should be used as the criterion for the amniotic fluid component of the biophysical profile (strong, moderate).
• 8.To ensure patient safety, care providers should develop clear protocols locally to communicate and document changes in fetal status identified during antenatal fetal surveillance and escalation of care (strong, moderate).
• 9.Care providers should use non-routine antenatal fetal health surveillance modalities, such as an NST, biophysical profile, or fetal Doppler sonography, only in the presence of a clear indication or finding associated with increased risk of fetal hypoxemia (strong, moderate).

     

Technical Update No. 433: eHealth Solutions for Urinary Incontinence Among Women

ObjectiveThe purpose of this technical update is to establish the state of the science regarding emerging and novel electronic health (eHealth) and mobile health (mHealth) solutions for urinary incontinence among women.Target populationWomen over 18 years with urinary incontinence.OptionsWebsites and mobile health applications are useful in the conservative care of urinary incontinence. Relevant care providers should be familiar with such tools, particularly those that use motivational principles for behaviour change, which can be used as adjunct tools for urinary incontinence care. Telemedicine is an effect mode to provide services for the conservative care of urinary incontinence.OutcomesUse of eHealth and mHealth solutions has potentially significant health outcomes for patients, providers, and global health systems. Broader use of telemedicine, in and of itself, could improve care access and reduce costs incurred by patients and the health care system.Benefits, Harms, and CostsEvidence for the efficacy of eHealth and mHealth technologies and applications for urinary incontinence ranges from weak to strong. However, the research landscape for many of these novel solutions is developing rapidly. Furthermore, these options have minimal or no harm and confer an established cost benefit and care access benefit.EvidenceThe Cochrane Library, Medline, EMBASE, CENTRAL databases (from January 2014 to April 2019) were searched to find articles related to conservative care of urinary incontinence in women (over 18 years) and studies on eHealth and mHealth interventions for urinary incontinence. Articles were appraised, and the collective evidence was graded.Validation methodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).Intended audienceRelevant primary care providers and medical specialists, including physicians, nurses, midwives, and pelvic health physiotherapists.SUMMARY STATEMENTS

• 1.Electronic and mobile health interventions for urinary incontinence are growing, both in their availability in the health care market and in the science to support their use (moderate).
• 2.Electronic health interventions offered in conjunction with pelvic floor muscle training, either self-directed or directed by a health care provider (physiotherapist), may provide a marginal benefit in symptom improvement for stress urinary incontinence among women (low).
• 3.Application- and web-based programming for urinary incontinence should include traditional components of self-management programs, including motivational strategies to support behavioural interventions (high).
• 4.Bladder diaries are the most studied electronic health tool for overactive bladder and urge urinary incontinence. The acceptability and feasibility of these mobile health solutions has been established (low).
• 5.There is limited research on how electronic health interventions improve urge urinary incontinence and overactive bladder (low).
• 6.Telehealth can be an effective platform for patient education and counselling on conservative and surgical management of uncomplicated stress urinary incontinence (high).

RECOMMENDATIONS

• 1.Mobile health solutions, such as applications that incorporate evidence-based, motivational, behavioural intervention principles, should be recommended to women with stress urinary incontinence if tailored in-person care is not available or accessible (strong, high).
• 2.There is currently insufficient evidence to recommend the routine use of electronic health interventions that include a physical device to improve stress urinary incontinence symptoms (conditional, very low).
• 3.Electronic health interventions may be recommended to complement stress urinary incontinence treatment, but providers should familiarize themselves with the specific interventions recommended, since they vary significantly in terms of composition, cost, and benefit (conditional, very low).
• 4.Health care providers remain the key knowledge translators and advisors on overactive bladder and urge urinary incontinence; they should not assume that patients will get the information they need from a website (strong, moderate).
• 5.Health care providers may recommend web-based self-management programs that incorporate evidence-based motivational behavioural intervention principles if tailored in-person care is not available or accessible to patients (strong, low).
• 6.Application-based bladder diaries may be used as an alternative to traditional bladder diaries as a self-monitoring tool (conditional, low).
• 7.Follow-up visits for uncomplicated stress urinary incontinence may be considered in women who are comfortable with this platform (strong, low).
• 8.Although there is insufficient evidence to recommend virtual or telehealth consultation for routine pessary care instructions, these platforms can be considered on a case-by-case basis depending on the patient’s comfort with pessary self-care (conditional, very low).
• 9.Surgical counselling for stress urinary incontinence via telehealth or virtual platforms may be considered for women who are comfortable with shared decision-making on these platforms (strong, moderate).
• 10.Post-operative virtual visits may be offered as an alternative to in-person visits after uncomplicated surgery for stress urinary incontinence (strong, moderate).

     

Guideline No. 435: Minimally Invasive Surgery in Fertility Therapy

ObjectiveTo evaluate the benefits and risks of minimally invasive procedures in the management of patients with infertility and provide guidance to gynaecologists who manage common conditions in these patients.Target PopulationPatients with infertility (inability to conceive after 12 months of unprotected intercourse) undergoing investigation and treatment.Benefits, Harms, and CostsMinimally invasive reproductive surgery can be used to treat infertility, improve fertility treatment outcomes, or preserve fertility. All surgery has risks and associated complications. Reproductive surgery may not improve fertility outcomes and may, in some instances, damage ovarian reserve. All procedures have costs, which are borne either by the patient or their health insurance provider.EvidenceWe searched English-language articles from January 2010 to May 2021 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library (see Appendix A for MeSH search terms).Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix B (Tables B1 for definitions and B2 for interpretations of strong and conditional [weak] recommendations).Intended AudienceGynaecologists who manage common conditions in patients with infertility.SUMMARY STATEMENTS

• 1.Laparoscopy is useful in determining the etiology of infertility if pelvic imaging has normal results (moderate).
• 2.Clinicians should question the therapeutic value of laparoscopy if fertility treatment is accessible and defer laparoscopy until such treatment proves unsuccessful (high).
• 3.In patients with minimal or mild endometriosis, resection or ablation significantly increases unassisted conception rates (moderate).
• 4.By extrapolation, a minimum of 20 patients with unexplained infertility would need to undergo laparoscopy to result in 1 additional unassisted conception (high).
• 5.In patients with multiple failed cycles of in vitro fertilization, laparoscopy may improve the cumulative pregnancy rate by increasing unassisted conception rates (low).
• 6.Fibroids of type 0–2 (submucosal) in the 2011 International Federation of Gynecology and Obstetrics (FIGO) staging system, and cavity-distorting intramural fibroids, are likely to have a negative effect on fertility (moderate).
• 7.It is unclear whether removing FIGO type 3–7 (non-cavity-distorting) fibroids increases pregnancy rates following fertility treatment (low).
• 8.Laparoscopic myomectomy may be preferable to laparotomy, depending on the number and size of the fibroids and the surgeon’s experience (low).
• 9.Surgical repair of distally occluded fallopian tubes can improve the likelihood of unassisted pregnancy but also increases the risk of ectopic pregnancy (low).
• 10.Removal or tubal ligation of unilateral hydrosalpinx may increase unassisted pregnancy rates (low).
• 11.Surgical repair or recanalization of proximal tubal obstruction results in unassisted pregnancy rates of 33% to 61% (low).
• 12.Ovarian cystectomy for benign, non-endometriosis cysts may negatively affect ovarian reserve, although to a lesser degree than endometrioma excision (moderate).
• 13.Laparoscopic ovarian drilling appears to be as effective as gonadotropins in inducing ovulation and clinical pregnancy but may result in lower live birth rates (low).
• 14.Ovarian transposition before radiotherapy appears to improve the probability of residual ovarian function (moderate).
• 15.The beneficial effect of ovarian transposition may be diminished in women over 30 years of age (low).
• 16.Unassisted pregnancy and live births are possible after ovarian transposition (very low).
• 17.Laparoscopic treatment of ovarian endometriosis and endometriomas must balance the improvement in fecundity with the damage to ovarian reserve (high).
• 18.Laparoscopy should not be regarded as the first-line treatment of infertility associated with endometriosis (high).
• 19.Laparoscopic endometrioma resection is associated with a lower recurrence rate than drainage and/or ablation, but it has a higher risk of negatively affecting ovarian reserve (moderate).

RECOMMENDATIONS

• 1.Laparoscopy should not be routinely offered in the initial evaluation of unexplained infertility (strong, high).
• 2.Laparoscopy can be offered to younger patients after unsuccessful fertility treatment (strong, high).
• 3.Clinicians may offer laparoscopy to patients with unexplained infertility and multiple failed cycles of in vitro fertilization (conditional, low).
• 4.Clinicians may consider myomectomy in patients with FIGO type 0–2 (submucosal) fibroids and unexplained infertility, particularly if the patient is undergoing fertility treatments (conditional, low).
• 5.Myomectomy is not recommended in asymptomatic patients with FIGO type 3–7 (non-cavity-distorting) fibroids for the sole purpose of increasing spontaneous conception rates (conditional, low).
• 6.Myomectomy should not be performed for the sole purpose of reducing miscarriage rates (conditional, low).
• 7.Distal tubal surgery should be reserved for patients in whom in vitro fertilization is not accessible (conditional, low).
• 8.Removal or ligation of hydrosalpinx before embryo transfer significantly increases pregnancy rates (strong, high).
• 9.Removal of non-endometriosis ovarian cysts for the sole purpose of increasing fertility is not recommended (conditional, moderate).
• 10.Laparoscopy is the recommended approach for ovarian cystectomy (conditional, moderate).
• 11.Sutures or hemostatic sealants are recommended over bipolar cautery for hemostasis during cystectomy (conditional, low).
• 12.Laparoscopic ovarian drilling can be considered in patients with polycystic ovary syndrome resistant to oral agents if gonadotropins are not accessible (conditional, moderate).
• 13.In patients undergoing pelvic radiotherapy, ovarian transposition should be considered to improve post-treatment ovarian function (conditional, moderate).
• 14.Before performing ovarian transposition pelvic radiation, clinicians should consider referral to a reproductive endocrinologist and possible egg/embryo cryopreservation. Although unassisted pregnancies and live births are possible after ovarian transposition, transvaginal ovarian access for in vitro fertilization is difficult. There is also a high probability that pelvic radiation will result in a uterine environment incapable of carrying a pregnancy, necessitating a gestational carrier (conditional, low).
• 15.While laparoscopic treatment is not first-line for infertility associated with endometriosis, it can be offered to patients with endometriosis and a history of infertility if there are other indications for surgery (e.g., pain); counselling should consider the patient’s age, duration of infertility, and ovarian reserve (conditional, low).
• 16.Patients should be comprehensively counselled about the risk that endometrioma surgery will diminish ovarian reserve (strong, high).
• 17.Laparoscopic endometrioma resection is indicated if there are concerns about access to the follicles for egg retrieval in in vitro fertilization (moderate, low).

     

Guideline No. 392-Pregnancy and Maternal Obesity Part 2: Team Planning for Delivery and Postpartum Care

ObjectiveThis guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on Preconception and Pregnancy Care. Part II will focus on Team Planning for Delivery and Postpartum Care.Intended UsersAll health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity.Target PopulationWomen with obesity who are pregnant or planning pregnancies.EvidenceLiterature 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, obstetric 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 September 2018. 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.Validation MethodsThe content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committees peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care.Benefits, Harms, and CostsImplementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affecting pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity.Guideline UpdateSOGC guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter.SponsorsThis guideline was developed with resources funded by the SOGC.Summary Statements

• 1Unfavourable cervix and induction of labour are more common with maternal obesity. The role of induction of labour and risk of Caesarean birth remains unclear (II-2).
• 2Electronic fetal monitoring is recommended for women in active labour with a body mass index >35 kg/m². Cervical assessment, uterine monitoring, and fetal heart rate monitoring may be more challenging with higher degrees of maternal body mass index (III).
• 3Decision-to-delivery time is increased in women with obesity (II-2).
• 4Body mass index increases risk of surgical site infection and wound complications (II-2).
• 5Anaesthetic risks are increased with maternal obesity (II-2).
• 6Rates of successful breastfeeding are reduced for women with obesity (II-2).
• 7Several effective contraceptive choices are available to women with obesity (III).
• 8Women with obesity are at higher risk of postpartum depression and anxiety (II-2).
• 9Antenatal, labour and delivery, and postnatal care may be more complex in women with obesity (III).

Recommendations

• 1Electronic fetal monitoring is recommended for women in active labour with a body mass index >35 kg/m². Intrauterine pressure catheters may assist in assessment of labour contractions. Fetal scalp electrodes may be helpful to ensure continuous fetal monitoring when indicated (III B).
• 2Women with obesity may benefit from higher dosage of preoperative antibiotics for Caesarean birth (I A).
• 3It is recommended to reapproximate the subcutaneous tissue layers at the time of Caesarean birth to reduce wound complications (II-2 A).
• 4Antenatal assessment with obstetric anaesthesia may assist in planning for safer birth for women with obesity (III A).
• 5Postoperative thromboprophylaxis is recommended, at appropriate dosing for the given body mass index, due to the greater risk of venous thromboembolism following Caesarean birth with women with obesity (II-3 A).
• 6Women with obesity should be offered lactation support in the postpartum period (III C)
• 7Women with obesity should be screened for postpartum depression and anxiety given that maternal obesity is a risk factor for these conditions (II-2 A).
• 8Counselling regarding weight management in the postpartum period is suggested in order to minimize risks in subsequent pregnancies (II-2 A).
• 9Obstetric team planning may be helpful for women with obesity to navigate the steps in antenatal, labour and delivery, and postnatal care (III-3 A).

     

Guideline No. 391-Pregnancy and Maternal Obesity Part 1: Pre-conception and Prenatal Care

ObjectiveThis guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on pre-conception and pregnancy care. Part II will focus on team planning for delivery and Postpartum Care.Intended UsersAll health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity.Target PopulationWomen with obesity who are pregnant or planning pregnancies.EvidenceLiterature 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 September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.Validation MethodsThe content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committee peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings, at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care.Benefits, Harms, and CostsImplementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affected pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity.Guideline UpdateSOGC guidelines will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter.SponsorsThis guideline was developed with resources funded by the SOGC.Summary Statements

• 1Maternal obesity carries both maternal and fetal risks (II-2).
• 2There are limited options for weight loss and management during pregnancy (II-2).
• 3Guidelines can assist with individualized recommendations regarding maternal gestational weight gain and calorie and nutrient intake during pregnancy (II-2).
• 4Maternal obesity is a risk factor for fetal macrosomia (II-2).
• 5The accuracy of fetal imaging for pregnancy dating, anatomical assessment, and fetal weight estimates is reduced in the setting of maternal obesity (II-2).
• 6Stillbirth is more common with maternal obesity (II-1).
• 7Multiple gestations carry additional risks in pregnancies complicated by maternal obesity (II-2).
• 8Weight loss surgery before pregnancy, while generally conferring benefits to mother and fetus, also carries rare and serious morbidity during gestation (II-1).

Recommendations

• 1Weight management strategies prior to pregnancy may include dietary, exercise, medical, and surgical approaches. When pursued before pregnancy, health benefits may carry forward into future pregnancies (III B).
• 2As obesity carries many medical risks, assessment for conditions of the cardiac, pulmonary, renal, endocrine, and skin systems, as well as obstructive sleep apnea, is warranted in the pre-pregnancy period (II-3 B).
• 3Folic acid supplementation in the 3 months prior to conception is warranted given the increased risks of congenital abnormalities of the fetal heart and neural tube related to maternal obesity (II-2 A).
• 4It is recommended that both monitoring of gestational weight gain and approaches for gestational weight gain management be formally integrated into routine prenatal care (III A).
• 5There is good evidence to support the role of exercise in pregnancy (I A).
• 6There is good evidence to support supplementation with folic acid (at least 0.4 mg) and vitamin D (400 IU) during pregnancy (II-2 A).
• 7Fetal macrosomia may be altered by well-controlled maternal gestational weight gain (II-2 A).
• 8Increased fetal surveillance for well-being is suggested in the third trimester if the reduced fetal movements are reported, given the increased rate of stillbirth (II-3).
• 9Aspirin prophylaxis can be recommended for women with obesity when other risk factors are present for the prevention of preeclampsia (I A).
• 10It is recommended that delivery be considered at 39–40 weeks gestation for women with a body mass index of 40 kg/m² or greater given the increased rate of stillbirth (II-2 A).
• 11Multiple gestations in women with obesity require increased surveillance and may benefit from consultation with a Maternal-Fetal Medicine consultant, especially in the setting of monochorionic gestations (II-2 A).
• 12Pregnancy after weight loss surgery may benefit from Maternal-Fetal Medicine consultation given the potential for significant albeit rare maternal morbidity (III B).

     

Guideline No. 437: Diagnosis and Management of Adenomyosis

ObjectiveTo describe the current evidence-based diagnosis and management of adenomyosis.Target PopulationAll patients with a uterus of reproductive age.OptionsDiagnostic options include transvaginal sonography and magnetic resonance imaging. Treatment options should be tailored to symptoms (heavy menstrual bleeding, pain, and/or infertility) and include medical options (non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, gonadotropin-releasing analogues), interventional options (uterine artery embolization), and surgical options (endometrial ablation, excision of adenomyosis, hysterectomy).OutcomesOutcomes of interest include reduction in heavy menstrual bleeding, reduction in pelvic pain (dysmenorrhea, dyspareunia, chronic pelvic pain), and improvement in reproductive outcomes (fertility, miscarriage, adverse pregnancy outcomes).Benefits, Harms, and CostsThis guideline will benefit patients with gynaecological complaints that may be caused by adenomyosis, especially those patients who wish to preserve their fertility, by presenting diagnostic methods and management options. It will also benefit practitioners by improving their knowledge of various options.EvidenceDatabases searched were MEDLINE Reviews, MEDLINE ALL, Cochrane, PubMed, EMBASE. The initial search was completed in 2021 and updated with relevant articles in 2022. Search terms included adenomyosis, adenomyoses, endometritis (used/indexed as adenomyosis before 2012), (endometrium AND myometrium) uterine adenomyosis/es, symptom/s/matic adenomyosis] AND [diagnosis, symptoms, treatment, guideline, outcome, management, imaging, sonography, pathogenesis, fertility, infertility, therapy, histology, ultrasound, review, meta-analysis, evaluation]. Articles included randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Articles in all languages were searched and reviewed.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations).Intended AudienceObstetrician-gynaecologists, radiologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, residents, and fellows.Tweetable AbstractAdenomyosis is common in reproductive-aged women. There are diagnostic and management options that preserve fertility available.SUMMARY STATEMENTS

• 1.Providers should be aware that adenomyosis has been associated with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes (moderate).

RECOMMENDATIONS

• 1.Transvaginal sonography should be the first-line modality for imaging of suspected adenomyosis in patients presenting with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes (strong, high).
• 2.Transvaginal sonography in patients presenting with symptoms suggestive of adenomyosis should be assessed by radiologists for the following: presence of features typical of adenomyosis, location, focal or diffuse disease, cystic or non-cystic disease, uterine layer involvement, extent of disease, and the size of the largest lesion or affected area (strong, high).
• 3.Magnetic resonance imaging should be considered by clinicians if there is inconclusive sonographic evaluation of adenomyosis or suspicion of significant concomitant pelvic pathology (conditional, moderate).
• 4.Oral contraceptives, levonorgestrel-releasing intrauterine system, and dienogest should be used as first-line medical options for pain and heavy menstrual bleeding from adenomyosis (strong, moderate).
• 5.Gonadotropin-releasing hormone (GnRH) agonists can be considered as a second-line agent for management of pain and heavy menstrual bleeding from adenomyosis; add-back hormones should be initiated if GnRH agonists are used longer than 6 months (strong, low).
• 6.Uterine artery embolization is an effective treatment option for heavy bleeding and pain associated with adenomyosis; it can be offered to patients who have completed child-bearing and would like to preserve their uterus (strong, moderate).
• 7.Minimally invasive thermal ablation procedures, such as high-intensity focused ultrasound, radiofrequency ablation, and percutaneous microwave ablation, might be used for the treatment of symptomatic adenomyosis in the future, but more data are needed before they are used outside of a research context (conditional, low).
• 8.Adenomyomectomy is an effective treatment option for symptomatic adenomyosis (strong, moderate).
• 9.Adenomyomectomy can be a challenging surgical procedure, with the potential for significant perioperative morbidity, and should be performed by an experienced surgeon (strong, low).
• 10.Focal adenomyosis may be amenable to surgical excision using minimally invasive routes (laparoscopy, robotic); however, diffuse adenomyosis is best approached using an open technique (conditional, low).
• 11.Given the substantial risk of intraoperative hemorrhage, anemia (hemoglobin <120 g/L) should be corrected before adenomyomectomy (strong, low).
• 12.Patients undergoing adenomyomectomy should be counselled about the uncertain impact of these procedures on fertility and pregnancy. They should be specifically informed about the increased risk of uterine rupture during pregnancy, and the need for pre-labour cesarean delivery (strong, low).
• 13.Total hysterectomy is an effective treatment option for symptomatic adenomyosis and can be offered to women who have completed child-bearing after appropriate counselling regarding risks, benefits, and alternative treatments (strong, low).
• 14.Patients with dysmenorrhea undergoing surgical management of adenomyosis should be counselled to have concurrent excision of any coexisting endometriosis during surgery, for more complete relief of their symptoms (strong, low).
• 15.The impact of adenomyosis on pregnancy outcomes in patients undergoing fertility treatments is uncertain (conditional, low).
• 16.For patients with adenomyosis undergoing in vitro fertilization, gonadotropin-releasing hormone agonist downregulation for a period of 2 to 4 months may be considered before transferring fresh or frozen embryos (weak, low).

     

Committee Opinion No. 406: Prenatal Testing After IVF With Preimplantation Genetic Testing for Aneuploidy

ObjectiveTo review the approach to prenatal genetic screening and diagnosis for chromosomal abnormalities in pregnancies conceived through in vitro fertilization and following preimplantation genetic testing for aneuploidy.Intended UsersGeneral practitioners, family physicians, obstetricians, midwives, nurses, maternal–fetal medicine specialists, fertility specialists, genetic counsellors, geneticists, and other health care providers involved in prenatal screening.Target PopulationAll individuals or couples who conceivd through in vitro fertilization and underwent preimplantation genetic testing for aneuploidy.EvidenceLiterature published in or before September 2018 was retrieved through searches of Medline, PubMed, and the Cochrane Library.SUMMARY STATEMENTS

• 1Preimplantation genetic testing for aneuploidy is a screening test for aneuploidy; its precise sensitivity and specificity are not known because of limited available data.
• 2Blastocyst mosaicism can contribute to errors (false positive and false negative results) in preimplantation genetic testing for aneuploidy and the results may or may not reflect the chromosomal complement of the inner cell mass.
• 3Traditional prenatal genetic screening algorithms for trisomies 21 and 18 are not appropriate for pregnancies conceived after preimplantation genetic testing for aneuploidy and euploid embryo transfer.
• 4Given the performance of preimplantation genetic testing for aneuploidy as a screening test, multiple marker screening (including enhanced first-trimester screening) for trisomies 21 and 18 is not recommended for pregnancies conceived after preimplantation genetic testing for aneuploidy and euploid embryo transfer.
• 5Non-invasive prenatal testing using maternal plasma circulating cell-free DNA for common aneuploidies can be considered for pregnancies conceived after preimplantation genetic testing for aneuploidy and euploid embryo transfer in combination with thorough genetic counselling of the patient.
• 6Universal screening for adverse pregnancy outcomes using maternal serum markers for aneuploidy is currently not recommended outside of an investigational protocol and with informed consent. This recommendation applies to pregnancies conceived by in vitro fertilization with or without preimplantation genetic testing for aneuploidy.
• 7All women who conceive after euploid embryo transfer with preimplantation genetic testing for aneuploidy should be offered an ultrasound scan between 11⁰ and 14⁰ weeks gestation.
• 8Any abnormal findings at the time of the ultrasound scan at 11⁰ to 14⁰ gestation should prompt a referral for consideration of invasive diagnostic testing, irrespective of history of preimplantation genetic testing for aneuploidy and euploid embryo transfer.
• 9Invasive diagnostic testing is not recommended for pregnancies conceived after preimplantation genetic testing for aneuploidy and transfer of a euploid embryo unless abnormal findings are detected on ultrasound or non-invasive prenatal testing indicates a high risk of aneuploidy.
• 10Genetic counselling is strongly recommended for all women considering the transfer of a mosaic embryo.
• 11All women who become pregnant after preimplantation genetic testing for aneuploidy and mosaic embryo transfer should be offered an ultrasound scan between 11⁰ and 14⁰ weeks gestation.
• 12Multiple marker screening is not recommended for pregnancies conceived after preimplantation genetic testing for aneuploidy and mosaic embryo transfer.
• 13Non-invasive prenatal testing is not recommended for pregnancies conceived after preimplantation genetic testing for aneuploidy and mosaic embryo transfer.
• 14In pregnancies conceived after mosaic embryo transfer, invasive diagnostic testing is highly recommended, with amniocentesis strongly preferred over chorionic villus sampling.
• 15Consultation with the genetic laboratory should take place prior to any invasive diagnostic procedure to ensure appropriate testing is initiated based on the results of preimplantation genetic testing for aneuploidy.

     

Guideline No. 395-Female Genital Cutting

ObjectivesTo decrease the likelihood that the practice of female genital cutting (FGC) be continued in the future and to improve the care of girls and women who have been subjected to FGC or who are at risk by providing (1) information intended to strengthen knowledge and understanding of the practice, (2) information regarding the legal issues related to the practice, (3) guidance for the management of its obstetrical and gynaecological complications, and (4) guidance on the provision of culturally competent care to girls and women affected by FGC.OptionsStrategies for the primary, secondary, and tertiary prevention of FGC and its complications.OutcomesThe short- and long-term consequences of FGC.Intended UsersHealth care providers delivering obstetrical and gynaecological care.Target PopulationWomen from countries where FGC is commonly practised and Canadian girls and women from groups who may practise FGC for cultural or religious reasons.EvidencePublished literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library in September 2010 using appropriate controlled vocabulary (e.g., Circumcision, Female) and key words (e.g., female genital mutilation, clitoridectomy, infibulation). Searches were updated and incorporated in the guideline revision December 2018.Validation MethodsThe quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.Benefits, Harms, and CostsThere are no anticipated harms or costs to health care facilities with implementation of this guideline. Benefits may include a greater willingness of women living with FGC to seek timely care.SUMMARY STATEMENTS

• 1Female genital cutting is internationally recognized as a harmful practice and a violation of girls’ and women's rights to life, physical integrity, and health (II-3).
• 2The immediate and long-term health risks and complications of female genital cutting can be serious and life-threatening (II-3).
• 3Female genital cutting continues to be practised in many countries, particularly in sub-Saharan Africa, Egypt, and Sudan (II-3).
• 4Global migration patterns have brought female genital cutting to Europe, Australia, New Zealand, and North America, including Canada (II-3).
• 5Performing or assisting in female genital cutting is a criminal offense in Canada (III).
• 6Reporting to appropriate child welfare protection services is mandatory when a child has recently been subjected to female genital cutting or is at risk of being subjected to the procedure (III).
• 7There is concern that female genital cutting continues to be perpetuated in receiving countries, mainly through the act of re-infibulation (III).
• 8There is a perception that the care of women with female genital cutting is not optimal in receiving countries (III).
• 9Female genital cutting is not considered an indication for cesarean section (III).

RECOMMENDATIONS

• 1Health care providers must be careful not to stigmatize women who have undergone female genital cutting (III-A).
• 2Requests for re-infibulation should be declined (III-B).
• 3Health care providers should strengthen their understanding and knowledge of female genital cutting and develop greater skills for the management of its complications and the provision of culturally competent care to girls and women who have undergone genital cutting (III-A).
• 4Health care providers should use their knowledge and influence to educate and counsel families against having female genital cutting performed on their daughters and other family members (III-A).
• 5Health care providers should advocate for the availability of and access to appropriate support and counselling services (III-A).
• 6Health care providers should lend their voices to community-based initiatives seeking to promote the elimination of female genital cutting (III-A).
• 7Health care providers should use interactions with patients as opportunities to educate women and their families about female genital cutting and other aspects of women's health and reproductive rights (III-A).
• 8Research into female genital cutting should be undertaken to explore women's perceptions and experiences of accessing sexual and reproductive health care in Canada (III-A). The perspectives, knowledge, and clinical practice of health care providers with respect to female genital cutting should also be studied (III-A).
• 9Information and guidance on female genital cutting should be integrated into the curricula for nursing students, medical students, residents, midwifery students, and students of other health care professions (III-A).
• 10Key practices in providing optimal care to women with female genital cutting include:
  • adetermining how the woman refers to the practice of female genital cutting and using this terminology throughout care (III-C).
  • bdetermining the female genital cutting status of the woman and clearly documenting this information in her medical record (III-C).
  • censuring the availability of a well-trained, trusted, and neutral interpreter who can ensure confidentiality and who will not exert undue influence on the patient-physician interaction when providing care to a woman who faces language challenges (III-C).
  • densuring the proper documentation of the woman's medical history in her record to minimize the need for repeated medical histories and/or examinations and to facilitate the sharing of information (III-C).
  • eproviding the woman with appropriate and well-timed information, including information about her reproductive system and her sexual and reproductive health (III-C).
  • fensuring the woman's privacy and confidentiality by limiting attendants in the room to those who are part of the health care team (III-C).
  • gproviding woman-centred care focused on ensuring that the woman's views and wishes are solicited and respected, including a discussion of why some requests cannot be granted for legal or ethical reasons (III-C).
  • hhelping the woman to understand and navigate the health system, including access to preventive care practices (III-C)
  • iusing prenatal visits to prepare the woman and her family for delivery (III-C).
  • jwhen referring, ensuring that the services and/or practitioners who receive the referral can provide culturally competent and sensitive care, paying special attention to concerns related to confidentiality and privacy (III-C).

     

Guideline No. 421: Point of Care Ultrasound in Obstetrics and Gynaecology

ObjectiveTo provide an opinion regarding the usefulness of point of care ultrasound in obstetrics and gynaecology.Target PopulationWomen with pregnancy-related complications or issues who could benefit from an urgent bedside sonographic evaluation.OptionsPoint of care ultrasound is a readily accessible option, requiring few resources.Benefits, Harms, and CostsThis low-cost imaging option can expedite appropriate patient management, enhance provider confidence, and allay the patient's anxiety in a timely fashion. However, there is potential for error in imaging or interpretation, resulting in incorrect and potentially harmful patient management.EvidenceMEDLINE, PubMed, Embase, and the Cochrane Library weres earched from 2009 to 2019. Medical Subject Headings (MeSH) and keywords were related to pregnancy, PoCUS, point of care ultrasound, and bedside ultrasound. This document represents an abstraction of the evidence rather than a methodological review.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended AudienceProviders of urgent care for pregnant women (obstetricians and gynaecologists, family physicians, emergency room physicians, midwives, nurse practitioners, nurses).SUMMARY STATEMENT (GRADE ratings in parentheses)

• 1Point of care ultrasound can provide timely and valuable information for management of several complications or issues that arise during pregnancy, labour and delivery, and the postpartum period (low).

RECOMMENDATIONS (GRADE ratings in parentheses)

• 1All units providing urgent care to pregnant women (including labour and delivery services) should strive to provide 24-hour access to point of care ultrasound (conditional, low).
• 2Training, accreditation, and quality assurance for point of care ultrasound should be guided by standards established by regional or local health authorities or local regulatory or credentialing bodies (conditional, low).