Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage

ObjectiveTo review the clinical aspects of postpartum hemorrhage (PPH) and provide guidelines to assist clinicians in the prevention and management of PPH. These guidelines are an update from the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical practice guideline on PPH, published in April 2000.EvidenceMedline, PubMed, the Cochrane Database of Systematic Reviews, ACP Journal Club, and BMJ Clinical Evidence were searched for relevant articles, with concentration on randomized controlled trials (RCTs), systematic reviews, and clinical practice guidelines published between 1995 and 2007. Each article was screened for relevance and the full text acquired if determined to be relevant. Each full-text article was critically appraised with use of the Jadad Scale and the levels of evidence definitions of the Canadian Task Force on Preventive Health Care.ValuesThe quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care.SponsorThe Society of Obstetricians and Gynaecologists of Canada.RecommendationsPrevention of Postpartum Hemorrhage

• 1.Active management of the third stage of labour (AMTSL) reduces the risk of PPH and should be offered and recommended to all women. (I-A)
• 2.Oxytocin (10 IU), administered intramuscularly, is the preferred medication and route for the prevention of PPH in low-risk vaginal deliveries. Care providers should administer this medication after delivery of the anterior shoulder. (I-A)
• 3.Intravenous infusion of oxytocin (20 to 40 IU in 1000 mL, 150 mL per hour) is an acceptable alternative for AMTSL. (I-B)
• 4.An IV bolus of oxytocin, 5 to 10 IU (given over 1 to 2 minutes), can be used for PPH prevention after vaginal birth but is not recommended at this time with elective Caesarean section. (II-B)
• 5.Ergonovine can be used for prevention of PPH but may be considered second choice to oxytocin owing to the greater risk of maternal adverse effects and of the need for manual removal of a retained placenta. Ergonovine is contraindicated in patients with hypertension. (I-A)
• 6.Carbetocin, 100 μg given as an IV bolus over 1 minute, should be used instead of continuous oxytocin infusion in elective Caesarean section for the prevention of PPH and to decrease the need for therapeutic uterotonics. (I-B)
• 7.For women delivering vaginally with 1 risk factor for PPH, carbetocin 100 μg IM decreases the need for uterine massage to prevent PPH when compared with continuous infusion of oxytocin. (I-B)
• 8.Ergonovine, 0.2 mg IM, and misoprostol, 600 to 800 μg given by the oral, sublingual, or rectal route, may be offered as alternatives in vaginal deliveries when oxytocin is not available. (II-1B)
• 9.Whenever possible, delaying cord clamping by at least 60 seconds is preferred to clamping earlier in premature newborns (< 37 weeks’ gestation) since there is less intraventricular hemorrhage and less need for transfusion in those with late clamping. (I-A)
• 10.For term newborns, the possible increased risk of neonatal jaundice requiring phototherapy must be weighed against the physiological benefit of greater hemoglobin and iron levels up to 6 months of age conferred by delayed cord clamping. (I-C)
• 11.There is no evidence that, in an uncomplicated delivery without bleeding, interventions to accelerate delivery of the placenta before the traditional 30 to 45 minutes will reduce the risk of PPH. (II-2C)
• 12.Placental cord drainage cannot be recommended as a routine practice since the evidence for a reduction in the duration of the third stage of labour is limited to women who did not receive oxytocin as part of the management of the third stage. There is no evidence that this intervention prevents PPH. (II-1C)
• 13.Intraumbilical cord injection of misoprostol (800 μg) or oxytocin (10 to 30 IU) can be considered as an alternative intervention before manual removal of the placenta. (II-2C)

Treatment of PPH

• 14.For blood loss estimation, clinicians should use clinical markers (signs and symptoms) rather than a visual estimation. (III-B)
• 15.Management of ongoing PPH requires a multidisciplinary approach that involves maintaining hemodynamic stability while simultaneously identifying and treating the cause of blood loss. (III-C)
• 16.All obstetric units should have a regularly checked PPH emergency equipment tray containing appropriate equipment. (II-2B)
• 17.Evidence for the benefit of recombinant activated factor VII has been gathered from very few cases of massive PPH. Therefore this agent cannot be recommended as part of routine practice. (II-3 L)
• 18.Uterine tamponade can be an efficient and effective intervention to temporarily control active PPH due to uterine atony that has not responded to medical therapy. (III-L)
• 19.Surgical techniques such as ligation of the internal iliac artery, compression sutures, and hysterectomy should be used for the management of intractable PPH unresponsive to medical therapy. (III-B)

Recommendations were quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1).     

Immunization in Pregnancy

ObjectiveTo review the evidence and provide recommendations on immunization in pregnancy.OutcomesOutcomes evaluated include effectiveness of immunization, risks and benefits for mother and fetus.EvidenceThe Medline and Cochrane databases were searched for articles published up to June 2008 on the topic of immunization in pregnancy.ValuesThe evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.Benefits, Harms, and CostsImplementation of the recommendations in this guideline should result in more appropriate immunization of pregnant and breastfeeding women, decreased risk of contraindicated immunization, and better disease prevention.RecommendationsThe quality of evidence reported in this document has been assessed using the evaluation of evidence criteria in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

• 1.All women of childbearing age should be evaluated for the possibility of pregnancy before immunization. (III-A)
• 2.Health care providers should obtain a relevant immunization history from all women accessing prenatal care. (III-A)
• 3.In general, live and/or live-attenuated virus vaccines should not be administered during pregnancy, as there is a, largely theoretical, risk to the fetus. (II-3B)
• 4.Women who have inadvertently received immunization with live or live-attenuated vaccines during pregnancy should not be counselled to terminate the pregnancy because of a teratogenic risk. (II-2A)
• 5.Non-pregnant women immunized with a live or live-attenuated vaccine should be counselled to delay pregnancy for at least four weeks. (III-B)
• 6.Inactivated viral vaccines, bacterial vaccines, and toxoids can be used safely in pregnancy. (II-1A)
• 7.Women who are breastfeeding can still be immunized (passive-active immunization, live or killed vaccines). (II-1A)
• 8.Pregnant women should be offered the influenza vaccine (including H1N1 vaccine, when it is available) when they are pregnant during the influenza season. (II-1A)
• 9.Pregnant women with suspected or documented H1N1 infection should be treated with oseltamivir (Tamiflu, 75 mg twice daily for 5 days) within 48 hours of onset of symptoms. (III-B)

     

Initial Evaluation and Referral Guidelines for Management of Pelvic/Ovarian Masses

ObjectivesTo optimize the management of adnexal masses and to assist primary care physicians and gynaecologists determine which patients presenting with an ovarian mass with a significant risk of malignancy should be considered for gynaecologic oncology referral and management.OptionsLaparoscopic evaluation, comprehensive surgical staging for early ovarian cancer, or tumour debulking for advanced stage ovarian cancer.OutcomesTo optimize conservative versus operative management of women with possible ovarian malignancy and to optimize the involvement of gynaecologic oncologists in planning and delivery of treatment.EvidencePublished literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified by searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.Recommendations

• 1.Primary care physicians and gynaecologists should always consider the possibility of an underlying ovarian cancer in patients in any age group who present with an adnexal or ovarian mass. (II-2B)
• 2.Appropriate workup of a perimenopausal or postmenopausal woman presenting with an adnexal mass should include evaluation of symptoms and signs suggestive of malignancy, such as persistent pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating. In addition, CA125 measurement should be considered. (II-2B)
• 3.Transvaginal or transabdominal ultrasound examination is recommended as part of the initial workup of a complex adnexal/ovarian mass. (II-2B)
• 4.Ultrasound reports should be standardized to include size and unilateral/bilateral location of the adnexal mass and its possible origin, thickness of septations, presence of excrescences and internal solid components, vascular flow distribution pattern, and presence or absence of ascites. This information is essential for calculating the risk of malignancy index II score to identify pelvic mass with high malignant potential. (IIIC)
• 5.Patients deemed to have a high risk of an underlying malignancy should be reviewed in consultation with a gynaecologic oncologist for assessment and optimal surgical management. (II-2B)

     

Management Guidelines for Obstetric Patients and Neonates Born to Mothers With Suspected or Probable Severe Acute Respiratory Syndrome (SARS)

ObjectiveThis document summarizes the limited experience of SARS in pregnancy and suggests guidelines for management.OutcomesCases reported from Asia suggest that maternal and fetal outcomes are worsened by SARS during pregnancy.EvidenceMedline was searched for relevant articles published in English from 2000 to 2007. Case reports were reviewed and expert opinion sought.ValuesRecommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.SponsorsThe Society of Obstetricians and Gynaecologists of Canada.Recommendations

• 1.All hospitals should have infection control systems in place to ensure that alerts regarding changes in exposure risk factors for SARS or other potentially serious communicable diseases are conveyed promptly to clinical units, including the labour and delivery unit. (III-C)
• 2.At times of SARS outbreaks, all pregnant patients being assessed or admitted to the hospital should be screened for symptoms of and risk factors for SARS. (III-C)
• 3.Upon arrival in the labour triage unit, pregnant patients with suspected and probable SARS should be placed in a negative pressure isolation room with at least 6 air exchanges per hour. All labour and delivery units caring for suspected and probable SARS should have available at least one room in which patients can safely labour and deliver while in need of airborne isolation. (III-C)
• 4.If possible, labour and delivery (including operative delivery or Caesarean section) should be managed in a designated negative pressure isolation room, by designated personnel with specialized infection control preparation and protective gear. (III-C)
• 5.Either regional or general anaesthesia may be appropriate for delivery of patients with SARS. (III-C)
• 6.Neonates of mothers with SARS should be isolated in a designated unit until the infant has been well for 10 days, or until the mother’s period of isolation is complete. The mother should not breastfeed during this period. (III-C)
• 7.A multidisciplinary team, consisting of obstetricians, nurses, pediatricians, infection control specialists, respiratory therapists, and anaesthesiologists, should be identified in each unit and be responsible for the unit organization and implementation of SARS management protocols. (III-C)
• 8.Staff caring for pregnant SARS patients should not care for other pregnant patients. Staff caring for pregnant SARS patients should be actively monitored for fever and other symptoms of SARS. Such individuals should not work in the presence of any SARS symptoms within 10 days of exposure to a SARS patient. (III-C)
• 9.All health care personnel, trainees, and support staff should be trained in infection control management and containment to prevent spread of the SARS virus. (III-A)
• 10.Regional health authorities in conjunction with hospital staff should consider designating specific facilities or health care units, including primary, secondary, or tertiary health care centres, to care for patients with SARS or similar illnesses. (III-A)

     

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).

     

Content of a Complete Routine Second Trimester Obstetrical Ultrasound Examination and Report

ObjectiveTo review the benefits of and requirements for a complete second trimester ultrasound and the documentation needed.OutcomesA complete second trimester ultrasound provides information about the number of fetuses, the gestational age, the location of the placenta, and fetal and maternal anatomy.EvidenceIn the production of this document, the American Institute of Ultrasound in Medicine’s “Practice Guideline for the Performance of Obstetric Ultrasound Examinations,” the American College of Obstetricians and Gynecologists’ practice bulletin, “Ultrasound in Pregnancy,” and the Royal College of Obstetricians and Gynaecologists’ Working Party Report, “Ultrasound Screening” were reviewed. PubMed and the Cochrane Database were searched using the words “routine second trimester obstetrical ultrasound.”ValuesThe evidence was evaluated using the guidelines developed by the Canadian Task Force on Preventive Health Care.Benefits, Harms, and CostsA routine complete second trimester ultrasound between 18 and 22 weeks and a complete ultrasound report will provide the best opportunity to diagnose fetal anomalies and to assist in the management of prenatal care. It will also reduce the number of ultrasound examinations done during the second trimester for completion of fetal anatomy survey. The costs are those involved with the performance of obstetrical ultrasound.ValidationThis is a revision of previous guidelines; information from other consensus reviews from medical publications has been used.SponsorsThe Society of Obstetricians and Gynaecologists of Canada.Recommendations

• 1.Pregnant women should be offered a routine second trimester ultrasound between 18 and 22 weeks’ gestation. (II-2B)
• 2.Second trimester ultrasound should screen for the number of fetuses, the gestational age, and the location of the placenta. (II-1A)
• 3.Second trimester ultrasound should screen for fetal anomalies. (II-2B)

     

Laparoscopic Entry: A Review of Techniques,Technologies, and Complications

ObjectiveTo provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications.OptionsThe laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems.OutcomesImplementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy.EvidenceEnglish-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.ValuesThe quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination.Recommandations et déclaration sommaire

• 1.Left upper quadrant (LUQ, Palmer’s) laparoscopic entry should beconsidered in patients with suspected or known periumbilicaladhesions or history or presence of umbilical hernia, or after threefailed insufflation attempts at the umbilicus. (II-2 A) Other sites ofinsertion, such as transuterine Veress CO₂ insufflation, may beconsidered if the umbilical and LUQ insertions have failed or havebeen considered and are not an option. (I-A)
• 2.The various Veress needle safety tests or checks provide very littleuseful information on the placement of the Veress needle. It istherefore not necessary to perform various safety checks oninserting the Veress needle; however, waggling of the Veressneedle from side to side must be avoided, as this can enlarge a1.6 mm puncture injury to an injury of up to 1 cm in viscera orblood vessels. (II-1 A)
• 3.The Veress intraperitoneal (VIP-pressure ≤ 10 mm Hg) is a reliableindicator of correct intraperitoneal placement of the Veress needle;therefore, it is appropriate to attach the CO₂ source to the Veressneedle on entry. (II-1 A)
• 4.Elevation of the anterior abdominal wall at the time of Veress orprimary trocar insertion is not routinely recommended, as it doesnot avoid visceral or vessel injury. (II-2 B)
• 5.The angle of the Veress needle insertion should vary according tothe BMI of the patient, from 45˚ in non-obese women to 90˚ inobese women. (II-2 B)
• 6.The volume of CO₂ inserted with the Veress needle shoulddepend on the intra-abdominal pressure. Adequatepneumoperitoneum should be determined by a pressure of 20 to30 mm Hg and not by predetermined CO₂ volume. (II-1 A)
• 7.In the Veress needle method of entry, the abdominal pressure maybe increased immediately prior to insertion of the first trocar. Thehigh intraperitoneal (HIP-pressure) laparoscopic entry techniquedoes not adversely affect cardiopulmonary function in healthywomen. (II-1 A)
• 8.The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniquescurrently available. (II-2 C)
• 9.Direct insertion of the trocar without prior pneumoperitoneum maybe considered as a safe alternative to Veress needle technique. (II-2)
• 10.Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. (I)
• 11.Shielded trocars may be used in an effort to decrease entryinjuries. There is no evidence that they result in fewer visceral andvascular injuries during laparoscopic access. (II-B)
• 12.Radially expanding trocars are not recommended as beingsuperior to the traditional trocars. They do have blunt tips that mayprovide some protection from injuries, but the force required forentry is significantly greater than with disposable trocars. (I-A)
• 13.The visual entry cannula system may represent an advantage overtraditional trocars, as it allows a clear optical entry, but thisadvantage has not been fully explored. The visual entry cannulatrocars have the advantage of minimizing the size of the entrywound and reducing the force necessary for insertion. Visual entrytrocars are non-superior to other trocars since they do not avoidvisceral and vascular injury. (2B)

     

The Evaluation of Stress Incontinence Prior to Primary Surgery

Objective: To provide clinical guidelines for the evaluation of women with stress urinary incontinence prior to primary anti-incontinence surgery.Options: The modalities of evaluation range from basic pelvic examination through to the use of adjuncts including ultrasound and urodynamic testing.Outcomes: These guidelines provide a comprehensive approach to the preoperative evaluation of urinary incontinence to ensure that excessive evaluation is avoided without sacrificing diagnostic accuracy.Evidence: Published opinions of experts, supplemented by evidence from clinical trials, where appropriate.Values: The quality of the evidence is rated using the criteria described by the Canadian Task Force on the Periodic Health Examination.Benefits, harms, and costs: Comprehensive evaluation of women considering surgery to treat urinary incontinence is essential to rule out causes of incontinence that may not be amenable to surgical treatment. Simplifying the evaluation minimizes the discomfort and embarrassment potentially experienced by women.Recommendations:

• 1. Thorough evaluation of each woman is essential to determine the underlying etiology of the urinary incontinence and to guide management. (II-3B)
• 2. Preoperative pelvic examination should be performed to identify pelvic masses that may provoke lower urinary tract symptoms (e.g., a large fibroid uterus impinging on the bladder), concomitant pelvic organ prolapse, and to rule out latent stress incontinence. All of these findings may necessitate a modification of the surgical approach. (III-C)
• 3. Hypermobility of the urethra should be confirmed preoperatively, as women with fixed, well-supported bladder necks are less likely to experience a cure following standard anti-incontinence procedures. (II-2B)
• 4. Stress incontinence should be objectively demonstrated prior to anti-incontinence surgery. (III-B)
• 5. The volume of postvoid residual urine should be measured prior to anti-incontinence surgery. Elevated postvoid residual volumes are uncommon and should signal the need for further evaluation of the voiding mechanism. (III-C)
• 6. Urinary tract infection should be identified and treated prior to initiating further investigation or therapeutic intervention for urinary incontinence. (II-2B)
• 7. In women presenting with pure stress incontinence that can be objectively demonstrated during examination, preoperative urodynamic testing is not necessary (II-3B). For women with other lower urinary tract symptoms and/or mixed urinary incontinence, the clinician’s judgment must guide the use of preoperative urodynamic testing (II-3B).

Validation: These guidelines have been approved by the Urogynaecology Committee and the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.     

Parvovirus B19 Infection in Pregnancy

ObjectivesThis guideline reviews the evidence relating to the effects of parvovirus B19 on the pregnant woman and fetus, and discusses the management of women who are exposed to, who are at risk of developing, or who develop parvovirus B19 infection in pregnancy.OutcomesThe outcomes evaluated were maternal outcomes including erythema infectiosum, arthropathy, anemia, and myocarditis, and fetal outcomes including spontaneous abortion, congenital anomalies, hydrops fetalis, stillbirth, and long-term effects.EvidencePublished literature was retrieved through searches of PubMed and The Cochrane Library on July 8, 2013, using appropriate controlled vocabulary (MeSH terms “parvovirus” and “pregnancy”) and key words (parvovirus, infection, pregnancy, hydrops). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions but results were limited to English or French language materials. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, and national and international medical specialty.ValuesThe quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).Recommendations

• 1.Investigation for parvovirus B19 infection is recommended as part of the standard workup for fetal hydrops or intrauterine fetal death. (II-2A)
• 2.Routine screening for parvovirus immunity in low-risk pregnancies is not recommended. (II-2E)
• 3.Pregnant women who are exposed to, or who develop symptoms of, parvovirus B19 infection should be assessed to determine whether they are susceptible to infection (non-immune) or have a current infection by determining their parvovirus B19 immunoglobulin G and immunoglobulin M status. (II-2A)
• 4.If parvovirus B19 immunoglobulin G is present and immunoglobulin M is negative, the woman is immune and should be reassured that she will not develop infection and that the virus will not adversely affect her pregnancy. (II-2A)
• 5.If both parvovirus B19 immunoglobulin G and immunoglobulin M are negative (and the incubation period has passed), the woman is not immune and has not developed the infection. She should be advised to minimize exposure at work and at home. Absence from work should be considered on a case-by-case basis. (II-2C) Further studies are recommended to address ways to lessen exposure including the risk of occupational exposure. (III-A)
• 6.If a recent parvovirus B19 infection has been diagnosed in the woman, referral to an obstetrician or a maternal–fetal medicine specialist should be considered. (III-B) The woman should be counselled regarding risks of fetal transmission, fetal loss, and hydrops and serial ultrasounds should be performed every 1 to 2 weeks, up to 12 weeks after infection, to detect the development of anemia (using Doppler measurement of the middle cerebral artery peak systolic velocity) and hydrops. (III-B) If hydrops or evidence of fetal anemia develops, referral should be made to a specialist capable of fetal blood sampling and intravascular transfusion. (II-2B)

     

Hemorrhagic Shock

Objective: To review the clinical aspects of hemorrhagic shock and provide recommendations for therapy.Options: Early recognition of hemorrhagic shock and prompt systematic intervention will help avoid poor outcomes.Outcomes: Establish guidelines to assist in early recognition of hemorrhagic shock and to conduct resuscitation in an organized and evidence-based manner.Evidence: Medline references were sought using the MeSH term “hemorrhagic shock.” All articles published in the disciplines of obstetrics and gynaecology surgery, trauma, critical care, anesthesia, pharmacology, and hematology between 1 January 1990 and 31 August 2000 were reviewed, as well as core textbooks from these fields. Selected references from these articles and book chapters were also obtained and reviewed. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination.Recommendations:

• 1.Clinicians should be familiar with the clinical signs of hemorrhagic shock. (III-B)
• 2.Clinicians should be familiar with the stages of hemorrhagic shock. (III-B)
• 3.Clinicians should assess each woman’s risk for hemorrhagic shock and prepare for the procedure accordingly. (III-B)
• 4.Resuscitation from hemorrhagic shock should include adequate oxygenation. (II-3A)
• 5.Resuscitation from hemorrhagic shock should include restoration of circulating volume by Placement of two largebore IVs and rapid infusion of a balanced crystalloid solution. (I-A)
• 6.Isotonic crystalloid or colloid solutions can be used for volume replacement in hemorrhagic shock (I-B). There is no place for hypotonic dextrose solutions in the management of hemorrhagic shock (I-E).
• 7.Blood component transfusion is indicated when deficiencies have been documented by clinical assessment or hematological investigations (II-2B ).They should be warmed and infused through filtered lines with normal saline, free of additives and drugs (II-3B).
• 8.Vasoactive agents are rarely indicated in the management of hemorrhagic shock and should be considered only when volume replacement is complete, hemorrhage is arrested, and hypotension continues. They should be administered in a critical care setting with the assistance of a multidisciplinary team. (III-B)
• 9.Appropriate resuscitation requires ongoing evaluation of response to therapy, including clinical evaluation, and hematological, biochemical, and metabolic assessments. (III-B)
• 10.In hemorrhagic shock, prompt recognition and arrest of the source of hemorrhage, while implementing resuscitative measures, is recommended. (III-B)

Validation: These guidelines have been reviewed by the Clinical Practice Obstetrics Committee and approved by Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.Sponsors: The Society of Obstetricians and Gynaecologists of Canada.     

Guidelines for the Management of Vasa Previa : No. 231, August 2009

Objectives

To describe the etiology of vasa previa and the risk factors and associated condition, to identify the various clinical presentations of vasa previa, to describe the ultrasound tools used in its diagnosis, and to describe the management of vasa previa.

Outcomes

Reduction of perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short-term and long-term maternal morbidity and mortality.

Evidence

Published literature on randomized trials prospective cohort studies, and selected retrospective cohort studies was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary (e.g., selected epidemiological studies comparing delivery by Caesarean section with vaginal delivery studies comparing outcomes when vasa previa is diagnosed antenatally vs. intrapartum) and key words (e.g. vasa previa). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated into the guideline to October 1, 2008. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and from national and international medical specialty societies.

Values

The evidence collected was reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care.

Benefits, Harms, and Costs

The benefit expected from this guideline is facilitation of optimal and uniform care for pregnancies complicated by vasa previa.

Sponsors

The Society of Obstetricians and Gynaecologists of Canada.     

Post-operative incontinence and fistulae

The proximity of the urinary tract to the reproductive organs puts it at risk of injury and incontinence as a consequence of gynaecological surgery.Incontinence of urine after gynaecological surgery is not only distressing and disappointing to the patient but also causes considerable stress to the surgeon. In particular, formation of a urinary fistula after surgery is seen as a disaster both by the patient and the surgeon. It also has long-term medico-legal implications.Post-operative incontinence can be broadly divided into two groups.

• •Patients who had incontinence before surgery
• •These women have surgery to address this problem in the first place. If surgery fails, the reasons could be:
• •inadequate evaluation and counselling before surgery,
• •inappropriate operation or operative technique,
• •development of detrusor instability,
• •unrecognized injury to the lower urinary tract.
• •Patients who did not have incontinence but developed this complaint after vaginal or abdominal surgery.
• •Here, incontinence develops as an undesired outcome of surgery. This may be due to:
• •retention with over flow in the immediate post-operative period,
• •inadequate evaluation before vaginal surgery unmasking occult incontinence,
• •unrecognized injury to the lower urinary tract.

In this article, the main emphasis will be on prevention, evaluation, diagnosis and management of urinary tract injury. Other causes of post-operative incontinence will be addressed briefly.A list of references has been provided for the interested reader.     

The medical management of endometriosis

• •Endometriosis is a chronic recurring disease in many women.
• •Can be asymptomatic but usually presents as pelvic pain or infertility.
• •The COCP, Danazol, progestogens and GnRHa have similar efficacy in relief of symptoms.
• •Treatment needs to be individualised, and may be determined by the side effect profile.
• •There is no role for medical therapy in the treatment of endometriosis infertility.

     

Antibiotic Therapy in Preterm Premature Rupture of the Membranes

ObjectiveTo review the evidence and provide recommendations on the use of antibiotics in preterm premature rupture of the membranes (PPROM).OutcomesOutcomes evaluated include the effect of antibiotic treatment on maternal infection, chorioamnionitis, and neonatal morbidity and mortality.EvidencePublished literature was retrieved through searches of Medline, EMBASE, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary and key words (PPROM, infection, and antibiotics). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and new material incorporated in the guideline to July 2008. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.ValuesThe evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.Benefits, Harms, and CostsGuideline implementation should assist the practitioner in developing an approach to the use of antibiotics in women with PPROM. Patients will benefit from appropriate management of this condition.ValidationThis guideline has been reviewed and approved by the Infectious Diseases Committee and the Maternal Fetal Medicine Committee of the SOGC, and approved by the Executive and Council of the SOGC.SponsorThe Society of Obstetricians and Gynaecologists of Canada.Recommendations

• 1.Following PPROM at ≤ 32 weeks’ gestation, antibiotics should be administered to women who are not in labour in order to prolong pregnancy and to decrease maternal and neonatal morbidity. (I-A)
• 2.The use of antibiotics should be gestational-age dependent. The evidence for benefit is greater at earlier gestational ages (< 32 weeks). (I-A)
• 3.For women with PPROM at > 32 weeks’ gestation, administration of antibiotics to prolong pregnancy is recommended if fetal lung maturity can not be proven and/or delivery is not planned. (I-A)
• 4.Antibiotic regimens may consist of an initial parenteral phase followed by an oral phase, or may consist of only an oral phase. (I-A)
• 5.Antibiotics of choice are penicillins or macrolide antibiotics (erythromycin) in parenteral and/or oral forms. (I-A) In patients allergic to penicillin, macrolide antibiotics should be used alone. (III-B)
• 6.The following two regimens may be used (the two regimens were used in the largest PPROM randomized controlled trials that showed a decrease in both maternal and neonatal morbidity): (1) ampicillin 2 g IV every 6 hours and erythromycin 250 mg IV every 6 hours for 48 hours followed by amoxicillin 250 mg orally every 8 hours and erythromycin 333 mg orally every 8 hours for 5 days (I-A); (2) erythromycin 250 mg orally every 6 hours for 10 days (I-A)
• 7.Amoxicillin/clavulanic acid should not be used because of an increased risk of necrotizing enterocolitis in neonates exposed to this antibiotic. Amoxicillin without clavulanic acid is safe. (I-A)
• 8.Women presenting with PPROM should be screened for urinary tract infections, sexually transmitted infections, and group B streptococcus carriage, and treated with appropriate antibiotics if positive. (II-2B)

     

Guideline No. 402: Diagnosis and Management of Placenta Previa

ObjectivesTo summarize the current evidence and to make recommendations for diagnosis and classification of placenta previa and for managing the care of women with this diagnosis.OptionsTo manage in hospital or as an outpatient and to perform a cesarean delivery preterm or at term or to allow a trial of labour when a diagnosis of placenta previa or a low-lying placenta is suspected or confirmed.OutcomesProlonged hospitalization, preterm birth, rate of cesarean delivery, maternal morbidity and mortality, and postnatal morbidity and mortality.Intended UsersFamily physicians, obstetricians, midwives, and other maternal care providers.Target PopulationPregnant women with placenta previa or low-lying placenta.EvidenceMedline, PubMed, Embase, and the Cochrane Library were searched from inception to October 2018. Medical Subject Heading (MeSH) terms and key words related to pregnancy, placenta previa, low-lying placenta, antepartum hemorrhage, short cervical length, preterm labour, and cesarean. This document represents an abstraction of the evidence rather than a methodological review.Validation MethodsThis guideline has been reviewed by the Maternal–Fetal Medicine and Diagnostic Imaging committees of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and approved by the SOGC Board of Directors.Benefits, Harms, and/or CostsWomen with placenta previa or low-lying placenta are at increased risk of maternal, fetal and postnatal adverse outcomes that include a potentially incorrect diagnosis and possibly unnecessary hospitalization, restriction of activities, early delivery, or cesarean delivery. Optimization of diagnosis and management protocols has potential to improve maternal, fetal and postnatal outcomes.SUMMARY STATEMENTS (GRADE ratings in parentheses)

• 1All women with placenta previa or low-lying placenta have an increased risk of a morbidly adherent placenta, particularly those who have had a prior cesarean delivery (strong/moderate).
• 2In women with placenta previa or a low-lying placenta, presence of a marginal/velamentous cord insertion close to the cervical os or a succenturiate placental lobe increases the risk of vasa previa (strong/moderate).
• 3History of antepartum hemorrhage (first episode <29 weeks or recurrent episodes [≥3]), a thick placental edge covering (or close to) the cervical os, short cervical length (<3 cm with placenta previa, <2 cm with low-lying placenta), and a previous cesarean delivery are risk factors with an associated increased risk of urgent/preterm cesarean delivery (strong/moderate).
• 4In the absence of risk factors, outpatient management of women with placenta previa is safe (strong/moderate).
• 5Bed rest or reduced activity is not beneficial in women with placenta previa and can be potentially harmful. However, sexual intercourse/insertion of foreign bodies in vagina or rectum should be avoided (conditional [weak]/low).
• 6Preoperative bedside ultrasound assessment of placental location can be useful for planning of surgical technique and may reduce risk of intraoperative transection of placenta (conditional [weak]/low).
• 7Regional anaesthesia is safe and adequate as a first-line anaesthetic approach for the peripartum management of patients with placenta previa or low-lying placenta (conditional [weak]/low).
• 8When deciding the location of delivery, consider ultrasound assessment of placental location, any risk factors, the patient's history, and logistical factors, including available resources at the delivery unit (conditional [weak]/low).

RECOMMENDATIONS (GRADE ratings in parentheses)

• 1Classify placental location as placenta previa (placenta covering the cervical os), low-lying placenta (edge located ≤20 mm from cervical os), or normally located placenta (edge located >20 mm from cervical os) (strong/moderate).
• 2Diagnosis of placenta previa or low-lying placenta should not be made <18 to 20 weeks gestation, and the provisional diagnosis must be confirmed after >32 weeks gestation, or earlier if the clinical situation warrants. In women with a low-lying placenta, a recent ultrasound (within 7 to 14 days) should be used to confirm placental location prior to a cesarean delivery (strong/moderate).
• 3Assessment by transvaginal ultrasound is recommended in all cases where placenta previa or a low-lying placenta is present or suspected by transabdominal sonography, with attempt to clearly define placental location (including laterality), characteristics of placental edge (including thickness, presence of a marginal sinus), and associated findings (succenturiate lobe, cord insertion close to the cervix) (strong/moderate).
• 4In women with placenta previa or low-lying placenta and in the presence of risk factors or limited access to urgent obstetrical care, consider in-hospital management (strong/moderate).
• 5A cervical cerclage can be considered in women with a short cervical length, particularly in association with antepartum hemorrhage, but not as a prophylactic measure for all women with placenta previa (conditional [weak]/low).
• 6Administer antenatal corticosteroids for potential preterm delivery only if the risk of delivery within 7 days is very high and not solely because admission to the hospital is deemed necessary (strong/moderate).
• 7Tocolysis can be considered in women with antepartum hemorrhage associated with uterine contractions in order to allow administration of corticosteroids or transfer of care, but not for prolongation of pregnancy (conditional [weak]/low).
• 8Cesarean delivery is recommended in women with placenta previa at 36⁰ to 36⁶ weeks gestation in the presence of risk factors and at 37⁰ to 37⁶ weeks gestation in the absence of risk factors (strong/moderate).
• 9Cesarean delivery is recommended in women with a low-lying placenta with the placental edge ≤10 mm from the cervical os at 37⁰ to 37⁶ weeks gestation in the presence of risk factors and at 38⁰ to 38⁶ weeks gestation in the absence of risk factors (strong/moderate).
• 10A trial of labour is recommended in women with a low-lying placenta where the placental edge is 11 to 20 mm from the cervical os and can be considered in carefully selected women where the placental edge is ≤10 mm from the cervical os (strong/moderate).

     

No. 381-Assisted Vaginal Birth

ObjectivesTo provide evidence-based guidelines for safe and effective assisted vaginal birth.OutcomesPrerequisites, indications, contraindications, along with maternal and neonatal morbidity associated with assisted vaginal birth.EvidenceMedline database was searched for articles published from January 1, 1985, to February 28, 2018 using the key words “assisted vaginal birth,” “instrumental vaginal birth,” “operative vaginal delivery,” “forceps delivery,” “vacuum delivery,” “ventouse delivery.” The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on Preventive Health Care.ValidationThese guidelines were approved by the Clinical Practice Obstetrics Committee and the Board of the Society of Obstetricians and Gynaecologists of Canada.Recommendations

• 1The need for assisted vaginal birth can be reduced by: dedicated and continuous support during labour (I-A), oxytocin augmentation of inadequate labour (I-A), delayed pushing in women with an epidural (I-A), increased time pushing in nulliparous women with an epidural (I-B), as well as optimization of fetal head position through manual rotation (I-A).
• 2Encouraging safe and effective assisted vaginal birth by experienced and skilled care providers may be a useful strategy to reduce the rate of primary Caesarean delivery (II-2B).
• 3Safe and effective assisted vaginal birth requires expertise in the chosen method, comprehensive assessment of the clinical situation alongside clear communication with the patient, support people, and health care personnel (III-B).
• 4Practitioners performing assisted vaginal birth should have the knowledge, skills, and experience necessary to assess the clinical situation, use the selected instrument, and manage complications that may arise from assisted vaginal birth (II-2B).
• 5Obstetrical trainees should receive comprehensive training in assisted vaginal birth and be deemed competent prior to independent practice (III-B).
• 6When assisted vaginal birth is deemed to have a higher risk of not being successful, it should be considered a trial of assisted vaginal birth and be conducted in a location where immediate recourse to Caesarean delivery is available (III-B).
• 7The physician should determine the instrument most suitable to the clinical circumstances and their level of skill. Vacuum and forceps are associated with different short- and long-term benefits and risks. Unsuccessful delivery is more likely with vacuum than forceps (I-A).
• 8Planned sequential use of instruments is not recommended as it may be associated with an increased risk of perinatal trauma. If an attempted vacuum is unsuccessful, the physician should consider the risks of proceeding to an attempted forceps delivery versus Caesarean section (II-2B).
• 9Restrictive use of mediolateral episiotomy is supported in assisted vaginal birth (II-2B).
• 10A debrief should be done with the patient and support people immediately following an attempted or successful assisted vaginal birth. If this is not possible, ideally this should be done prior to hospital discharge and include the indication for assisted vaginal birth, management of any complications, and the prognosis for future deliveries (III-B).
• 11In a subsequent pregnancy, patients should be encouraged to consider spontaneous vaginal birth. However, care planning should be individualized and patient preference respected (II-3B).

     

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).

     

Automobile trauma in pregnancy: Prevention and treatment

Trauma remains a significant problem for pregnant women. This article discusses the physiology, emergency management, and prevention of injury in pregnant automobile accident victims. The following are the most important messages:

• 1.1) The mere presence of pregnancy should not alter initial emergency trauma resuscitation and subsequent management.
• 2.2) Similarly, pregnancy should not discourage obtaining x-rays necessary for appropriate diagnosis of trauma victims.
• 3.3) Following trauma, the sympathetic responses of the mother divert blood flow away from the pregnant uterus and other “nonvital” organs. Under such circumstances, the fetus may become hypoxic and die, even while the maternal vital signs remain within normal limits.
• 4.4) An experienced labor nurse should be assigned to the trauma victim as soon as possible, and the electronic fetal monitor should be applied by and observed by this nurse until stabilization of the victim has occurred and the patient is admitted to the hospital.
• 5.5) The patient's obstetrician should be brought into the emergency care management as soon as possible—one of his/her assignments is to be the physician/advocate for the fetus.
• 6.6) Placental separation occurs frequently in trauma victims, and in some situations maternal clinical signs may not be evident. Under such circumstances, there is usually some evidence of fetal compromise.
• 7.7) Pregnant women and all children should use automobile restraint systems.

     

Diagnosing Chromosomal Abnormalities From “Big” to “Small” With Molecular Cytogenetic Technology

We reviewed the available molecular cytogenetic techniques and their potential use in prenatal diagnosis of fetuses with multiple congenital anomalies and a “normal” standard chromosomal karyotype. We searched Medline to identify reports published after 1995 that were related to molecular prenatal diagnosis. After review, we reached the following conclusions:

• 1.In fetuses with a normal standard karyotype result, common chromosomal microdeletion syndromes may be suspected based on the pattern of congenital anomalies seen on prenatal ultrasound.
• 2.When a microdeletion syndrome is suspected based on the pattern of fetal anomalies, FISH testing for the specific molecular locus should be undertaken.
• 3.Routine chromosome analysis, which has been the gold standard for prenatal cytogenetic diagnosis, may in the future be replaced by microarray technology with increased diagnostic capability for smaller, submicroscopic genetic alterations associated with postnatal morbidity.
• 4.Microarray technology has been shown to increase our ability to make a diagnosis of known or new chromosomal deletion syndromes in pediatric populations with developmental delay. The use of this technology for prenatal diagnosis is currently limited but is likely to expand.

     

Current methods of urinary fistulae repair

The basic principles in the management of urinary fistulae are:

• 1.1. Pre-operative assessment to formulate a plan of action
• 2.2. Tissue mobilisation so that repair is performed without tension
• 3.3. Continuous bladder drainage for 14 days.

With ureteric fistulae the aim is to reimplant viable ureter into healthy bladder without tension and prevent reflux. Delayed repair (2 to 3 months) of vesico-vaginal fistulae is advisable.Spontaneous healing occurs in some small vesico-vaginal fistulae and more rarely in uretero-vaginal fistulae.