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. 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. 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).

     

Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology

ObjectiveTo provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates.Target populationProviders working to improve health care for Canadian women and their families; patients and their families.OutcomesSimulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition.Benefits, Harms, and CostsThis modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time.EvidenceArticles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords “simulation” and “simulator.” The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered.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 AudienceAll health care professionals working to improve Canadian women’s health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs.Recommendations

• 1.Health care professionals in obstetrics and gynaecology should understand the value of both in situ and off-site simulation as a tool for education, patient safety, and quality improvement at both the team and individual levels (strong, moderate).
• 2.Health care professionals in obstetrics and gynaecology should be aware of the overall cost reduction associated with the use of simulation (strong, moderate).
• 3.Stakeholders at all levels must commit to an ongoing simulation program, including identifying, training, and supporting simulation advocates, as well as securing adequate funding. This approach leads not only to organizational readiness but also to quality improvement and positive culture change (strong, moderate).
• 4.Providers of obstetrical and gynaecological care should be familiar with key simulation modalities and principles of how to advance knowledge using simulation (conditional, low).
• 5.Purposeful simulation activities must be based on local needs assessments and knowledge gaps (conditional, low).
• 6.Interprofessional/interdisciplinary teams should participate in the design, implementation, and evaluation of team training and in situ simulation programs (strong, high).
• 7.Debriefing must be promoted as a fundamental component of the experiential learning process. Team debriefing/peer debriefing with a written guide can be as effective (as an alternative) as expert debriefing (strong, high).
• 8.Psychological safety must be established for all personnel within the simulation and the debriefing (strong, moderate).
• 9.Program evaluation, a system to measure the efficacy of a learning activity, must be included in the planning of simulation activities to assess whether the targeted outcomes of the program were achieved (strong, moderate).
• 10.Simulation-based activities should be designed in a culturally sensitive and socially responsible way, similar to all other aspects of health professionals’ education (strong, low).

     

Technical Update No. 438: Antenatal Corticosteroids at Late Preterm Gestation

ObjectiveTo update recommendations for administration of antenatal corticosteroids in the late preterm period.Target PopulationPregnant individuals at risk of preterm birth from 34⁰ to 36⁶ weeks gestation.OptionsAdministration or non-administration of a single course of antenatal corticosteroids at 34⁰ to 36⁶ weeks gestation.OutcomesNeonatal morbidity (respiratory distress, hypoglycemia), long-term neurodevelopment, and other long-term outcomes (growth, cardiac/metabolic, respiratory).Benefits, Harms, and CostsAdministration of antenatal corticosteroids from 34⁰ to 36⁶ weeks gestation decreases the risk of neonatal respiratory distress but increases the risk of neonatal hypoglycemia. The long-term impacts of antenatal corticosteroid administration from 34⁰ to 36⁶ weeks gestation are uncertain.EvidenceFor evidence on the neonatal effects of antenatal corticosteroid administration at late preterm gestation, we summarized evidence from the 2020 Cochrane review of antenatal corticosteroids and combined this with evidence from published randomized trials identified by searching Ovid MEDLINE from January 1, 2020, to May 11, 2022. Given the absence of direct evidence on the impact of late preterm antenatal corticosteroid administration on neurodevelopmental outcomes, we summarized evidence on the impact of antenatal corticosteroids across gestational ages on neurodevelopmental outcomes using the following sources: (1) the 2020 Cochrane review; and (2) evidence obtained by searching Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to January 5, 2022. We did not apply date or language restrictions. Given the absence of direct evidence on the impact of late preterm antenatal corticosteroid administration on other long-term outcomes, we summarized evidence on the impact of antenatal corticosteroids across gestational ages on other long-term outcomes by combining findings from the 2020 Cochrane review with evidence obtained by searching Ovid MEDLINE for observational studies related to long-term cardiometabolic, respiratory, and growth effects of antenatal corticosteroids from inception to October 22, 2021. We reviewed reference lists of included studies and relevant systematic reviews for additional references. See Appendix A for search terms and summaries.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 AudienceMaternity care providers, including midwives, family physicians, and obstetricians.SUMMARY STATEMENTS

• 1.Evidence suggests that antenatal corticosteroid administration at preterm gestation is associated with reduced perinatal morbidity and mortality. The balance of absolute benefits and harms of antenatal corticosteroid administration changes at late preterm gestation compared with earlier gestational ages (moderate).
• 2.Late preterm antenatal corticosteroid administration (i.e., at 34⁰ to 36⁶ weeks gestation) decreases the risk of neonatal respiratory morbidity but increases the risk of neonatal hypoglycemia (high).
• 3.Late preterm antenatal corticosteroid administration in pregnant individuals with pre-gestational diabetes mellitus may worsen neonatal hypoglycemia (low).
• 4.The impact of late preterm antenatal corticosteroids on neurodevelopment and other long-term outcomes remains uncertain (low).
• 5.Further research is needed to determine the optimal dose of antenatal corticosteroids (moderate).

RECOMMENDATIONS

• 1.We continue to strongly recommend antenatal corticosteroid administration up to 33⁶ weeks gestation when delivery is expected within 7 days (strong, high).
• 2.We have changed the upper gestational age boundary to which we strongly recommend antenatal corticosteroid administration from 34⁰ to 33⁶ weeks gestation (conditional, low).
• 3.For pregnant individuals at risk of delivery between 34⁰ and 36⁶ weeks gestation, we recommend considering antenatal corticosteroids based on discussion with patients about absolute harms and benefits specific to the gestational week (strong, moderate).
• 4.Between 34⁰ and 36⁶ weeks gestation, we do not recommend antenatal corticosteroids for pregnancies with pre-gestational diabetes in most cases. The greater risk of hypoglycemia in these pregnancies should be considered as part of the discussion on harms and benefits of antenatal corticosteroids (conditional, low).

     

Guideline No. 440: Management of Monochorionic Twin Pregnancies

ObjectiveThis guideline reviews the evidence-based management of normal and complicated monochorionic twin pregnancies.Target PopulationWomen with monochorionic twin or higher order multiple pregnancies.Benefits, Harms, and CostsImplementation of these recommendations should improve the management of both complicated and uncomplicated monochorionic (and higher order multiple) twin pregnancies. They will help users monitor monochorionic twin pregnancies appropriately and identify and manage monochorionic twin complications optimally in a timely manner, thereby reducing perinatal morbidity and mortality.These recommendations entail more frequent ultrasound monitoring of monochorionic twins compared to dichorionic twins.EvidencePublished literature was retrieved through searches of PubMed and the Cochrane Library using appropriate MeSH headings (Twins, Monozygotic; Ultrasonography, Prenatal; Placenta; Fetofetal Transfusion; Fetal Death; Fetal Growth Retardation). Results were restricted to systematic reviews, randomized controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials.Validation MethodsThe content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The 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 AudienceMaternal-fetal medicine specialists, obstetricians, radiologists, sonographers, family physicians, nurses, midwives, residents, and other health care providers who care for women with monochorionic twin or higher order multiple pregnancies.Tweetable AbstractCanadian (SOGC) guidelines for the diagnosis, ultrasound surveillance and management of monochorionic twin pregnancy complications, including TTTS, TAPS, sFGR (sIUGR), acardiac (TRAP), monoamniotic twins and intrauterine death of one MC twin.SUMMARY STATEMENTS

• 1.Morbidity and mortality in twin pregnancies are most commonly related to: (1) chorionicity, (2) prematurity, (3) fetal growth restriction, and (4) congenital anomalies (high).
• 2.Virtually all monochorionic placentas have vascular anastomoses between the two placental cord insertions (high).
• 3.Besides prematurity and growth discordance, the vast majority of twin complications arise in monochorionic twin pregnancies (high).
• 4.Twin–twin transfusion syndrome affects approximately 10%–15% of monochorionic twin pregnancies (high).
• 5.The diagnosis of twin–twin transfusion syndrome is based on ultrasound findings of significant discordance in both amniotic fluid volume and bladder size (high). Cardiac dysfunction in the recipient twin or growth discordance often co-exist, but are not essential criteria for the diagnosis (high).
• 6.Fetoscopic laser ablation of the placental vascular anastomoses is the best treatment for twin-twin transfusion syndrome presenting before 28-30 weeks gestation, rather than amnioreduction or septostomy (high).
• 7.The Solomon laser technique decreases the risk of twin–twin transfusion syndrome recurrence and twin anaemia-polycythaemia sequence (high).
• 8.Twin anaemia-polycythaemia sequence occurs spontaneously in 4%–5% of monochorionic twin pregnancies (moderate). It typically develops later in pregnancy than twin–twin transfusion syndrome (usually >24–26 weeks gestation) (moderate). Twin anaemia-polycythaemia sequence may co-exist with twin–twin transfusion syndrome and has been reported in up to 13% of cases of TTTS in which the fetoscopic laser ablation procedure was incomplete (high).
• 9.Ultrasound features of twin anaemia-polycythaemia sequence are increasingly discordant middle cerebral artery peak systolic velocities, suggestive of anaemia in one fetus and polycythaemia in the other, often without significant amniotic fluid discordance (high). Other signs may include differential placental echogenicities and a “starry sky” liver in the recipient twin (moderate).
• 10.Selective fetal growth restriction in monochorionic twin pregnancies has been defined as an estimated fetal weight (EFW) of one twin below the 3^rd percentile, or at least 2 of the following four variables: (1) EFW <10^th percentile, (2) abdominal circumference <10^th percentile, (3) EFW discordance ≥25%, or (4) umbilical artery pulsatility index of the smaller twin >95^th percentile (high).
• 11.In monochorionic twins, estimated fetal weight discordance >25% and abnormal umbilical artery Doppler waveforms are independent risk factors for an adverse perinatal outcome. (high).
• 12.The ultrasonographic features of twin reversed arterial sequence are an amorphous, usually edematous, acardiac twin, which is retrogradely perfused via a placental artery-to-artery anastomosis by its healthy “pump” co-twin (high).
• 13.A large acardiac twin (e.g., an acardiac:“pump” twin abdominal circumference ratio ≥50%) may put its “pump” co-twin at risk of high-output cardiac failure (high). The overall risk of intrauterine death of the “pump” twin is approximately 30% before 18 weeks gestation (high).
• 14.If one of a monochorionic twin pair dies, the surviving co-twin may be at risk of neurological morbidity and intrauterine death (high). Imaging may not detect changes in the co-twin’s brain for several weeks after the death of its sibling (moderate).
• 15.Ultrasound features of monoamniotic twins include the absence of a dividing amniotic membrane, a single placenta, close proximity of placental cord roots, concordant sex and, commonly, cord entanglement (high).
• 16.Only 2%–4% of monoamniotic twins will develop twin–twin transfusion syndrome (high).
• 17.Structural anomalies, particularly cardiac, are more common in monochorionic twins than in dichorionic twins or singletons (high).
• 18.Conjoined twins are extremely rare and the organs/structures that are shared will determine the potential for surgical intervention and survival (high).

RECOMMENDATIONS

• 1.In spontaneously conceived pregnancies, we recommend using the larger of the two crown–rump lengths to estimate gestational age (conditional, moderate).
• 2.Viability, gestational age, chorionicity and amnionicity should be assessed between 11⁰ and 13⁶ weeks gestation in all multiple pregnancies (strong, high).
• 3.If chorionicity cannot be confidently established sonographically, pregnancies should be monitored as if they were monochorionic (conditional, moderate).
• 4.Twins should be labelled on antenatal ultrasound according to their lateral (right/left) or vertical (top/bottom) orientation, rather than their proximity to the cervix, and, ideally, that labelling should be maintained across all subsequent ultrasound examinations (strong, moderate).
• 5.A detailed anatomy scan should be performed at approximately 18–20 weeks gestation for all monochorionic twins (strong, high). Where the expertise is available, an early anatomy ultrasound can be performed at 12–14 weeks gestation (conditional, moderate).
• 6.In all twin pregnancies, cervical length should be assessed, either transabdominally or transvaginally, at the time of the anatomical ultrasound scan and, ideally, once more at around 23–24 weeks gestation (strong, moderate).
• 7.All monochorionic pregnancies should undergo ultrasound surveillance every 2 weeks from 16 weeks gestation until delivery to detect twin–twin transfusion syndrome, twin anaemia-polycythaemia sequence and selective fetal growth restriction (strong, high).
• 8.Ultrasound assessment of all monochorionic twins from 16 weeks onwards should include measurement of growth (fetal biometry), fetal bladder filling, and the single deepest pocket of amniotic fluid on both sides of the membrane, as well as umbilical and middle cerebral artery peak systolic velocity Doppler studies for each fetus (strong, high).
• 9.Monochorionic twins without complications should be delivered between 36 and 37 weeks gestation. Unless there are other obstetric contraindications, vaginal delivery is appropriate (strong, high).
• 10.If twin–twin transfusion syndrome or significant selective fetal growth restriction is suspected, the ductus venosus should be assessed (strong, high). Cardiac structure and function should be assessed in the recipient twin whenever twin–twin transfusion syndrome is suspected (strong, high).
• 11.For cases of twin–twin transfusion syndrome, urgent consultation with or referral to one of the fetal therapy laser centres in Canada is recommended, as fetoscopic laser ablation of placental vascular anastomoses is the best therapy for twin–twin transfusion syndrome (strong, high).
• 12.Ultrasonography should be performed weekly for 4 weeks after fetoscopic placental laser and then every 2 weeks following clinical resolution, with ongoing antenatal care shared or co-ordinated with the regional maternal–fetal medicine centre (strong, high). Assessment should include amniotic fluid volume in both sacs, bladder sizes, Doppler waveforms (middle cerebral artery peak systolic velocity, umbilical artery pulsatility index and ductus venosus), and intra-cranial anatomies, as well as measurement of cervical length and documentation of any chorio-amnion separation (strong, high).
• 13.Fetal intracranial anatomy should be carefully re-evaluated after an interval of at least 4 weeks following a laser procedure (strong, moderate).
• 14.Whenever monochorionic twin complications are encountered, including twin anaemia-polycythaemia sequence, selective fetal growth restriction, twin reversed arterial perfusion sequence, monoamnioticity, discordance for an anomaly, or a single intrauterine death, referral to, or at least consultation with, the regional maternal–fetal medicine program or fetal therapy centre is recommended (strong, high), so that all management options can be explored. The optimal management of twin anaemia-polycythaemia sequence has yet to be determined. (conditional, moderate).
• 15.When selective fetal growth restriction is suspected, fetal surveillance should be intensified and the pregnancy managed by referral to, or at very least with input from, a regional maternal–fetal medicine centre with expertise in this condition (strong, moderate).
• 16.In selective fetal growth restriction, timing of delivery should take into account gestational age, evidence of haemodynamic compromise as assessed by umbilical and middle cerebral artery and ductus venosus Doppler studies, and biophysical wellbeing (strong, moderate).
• 17.Whenever the death of one monochorionic twin is diagnosed early in pregnancy, colour Doppler ultrasonography should be used to exclude twin reversed arterial perfusion sequence, by confirming the absence of blood flow in the suspected demised twin (strong, high).
• 18.In twin reversed arterial perfusion sequence, especially with a large acardiac twin, occlusion of the circulation to the acardiac twin, either by laser, radio frequency ablation of the intra-fetal vessels or bipolar cautery should be considered (conditional, moderate).
• 19.After the spontaneous death of one monochorionic twin, surveillance for fetal anaemia by middle cerebral artery peak systolic velocity measurement should be instituted rapidly, as anaemia correlates with the risk of a hypotensive neurological injury (strong, high). The surviving twin may benefit from intrauterine transfusion (conditional, moderate). Fetal neurosonography and, ideally, MRI should be used to identify any potential cerebral injury; however, ultrasonographic evidence of injury may take 3-4 weeks to develop after the death of the co-twin (strong, high).
• 20.Care should be taken not to misdiagnose monochorionic-diamniotic pregnancies as monoamniotic, when one twin has anhydramnios (e.g., the donor in twin–twin transfusion syndrome) (conditional, moderate).
• 21.Monoamniotic twins are at high risk of cardiac abnormalities and should undergo a detailed anatomical ultrasound with particular emphasis on fetal cardiac evaluation (strong, high).
• 22.Monoamniotic twins should be monitored closely from viability onwards (either as out-patients or in-patients) and should undergo an elective caesarean delivery at approximately 33 weeks gestation (conditional, moderate).
• 23.Aneuploidy screening can be offered in monochorionic pregnancies as either combined prenatal serum screening (i.e., first-trimester screening or integrated prenatal screening, as available provincially) or cell-free fetal DNA analysis of maternal blood (conditional, moderate).
• 24.Invasive prenatal testing (chorionic villus sampling or amniocentesis) should be offered in the presence of a structural anomaly or abnormal genetic screening (strong, high). Amniocentesis from both sacs should be considered for discordant anomalies because of the rare possibility of heterokaryotypic anomalies in monochorionic twins (strong, high).
• 25.If indicated for discordance for an anomaly, selective termination of pregnancy in monochorionic twins must always be performed by a vascular occlusion method and never by intravascular fetal injection (strong, high).

     

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).

     

Technical Update No. 436: Classification of Cesarean Deliveries in Canada: The Modified Robson Criteria

ObjectiveTo describe and advocate for the use of a common classification system for cesarean delivery in Canada.Target populationPregnant individuals undergoing cesarean delivery.Benefits, harms, costsUse of a standardized classification system for cesarean delivery allows for local, regional, national, and international comparison of cesarean delivery rates and trends. The system is inclusive and simple to implement, based on existing databases.EvidenceA comprehensive literature review was updated to April 2022 with medical subject headings (MeSH) and keywords (cesarean section, classification, taxonomy, nomenclature, terminology) in MEDLINE/PubMed and Embase databases. Results were restricted to systematic reviews, randomized controlled trials and clinical trials, and observational studies. Additional literature was identified by backward citation tracking using relevant full-text articles. The grey literature was reviewed by searching websites of health agencies.Validation methodsThe authors rated the quality of evidence and strength of recommendation using the Grade of Recommendations, Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretation of strong and conditional [weak] recommendations).The Board of the SOGC approved the final draft for publication.Intended AudienceObstetric care providers, health care administrators, epidemiologists.RECOMMENDATIONS

• 1.The modified Robson classification system should be used to enable monitoring, assessment, and comparison of cesarean delivery rates (strong, moderate).
• 2.The factors leading to the decision to proceed with a cesarean delivery should be clearly documented (strong, moderate).