Joel Ray

St. Michael's Hospital | SMH · Medicine and Obstetrics and Gynaecology

STUDY QUESTION What is the association between infertility with or without fertility treatment and incident onset of systemic autoimmune rheumatic disease (SARD) among women who give birth? SUMMARY ANSWER Women who experienced infertility but did not use fertility treatment had a higher incidence of SARD up to 9 years after delivery than those who...

This case-control study investigates the risk of rhabdomyolysis among patients receiving sodium-glucose cotransporter-2 (SGLT2) inhibitors.

Background Administration of chemotherapy during pregnancy is often delayed, while preterm delivery is common. If in utero exposure to chemotherapy is associated with adverse pediatric outcomes, it is unknown whether that relationship is directly attributable to the chemotherapy or is mediated by preterm birth. Methods Cases were identified from C...

This cohort study examines whether there is an association between a mother moving into a neighborhood with lower income between births and newborn custody by child protective services at birth.

Importance Newborn immunity largely relies on maternal-fetal transfer of antibodies in utero. Incongruency in ABO blood groups between a mother and newborn may be associated with protection against serious infections, but data specific to newborn bacterial infections are lacking. Objective To ascertain the association between maternal-newborn ABO...

(Abstracted from JAMA Netw Open. 2024;7:e248676) Midwives work in conjunction with obstetrics professionals and collaborate with other specialists when clinically indicated. Women receiving obstetrics care are often discharged quickly after birth and have only 1 follow-up visit at 6 weeks postpartum.

Background: Use of a gestational (“surrogate”) carrier is increasingly common. Risk for maternal and neonatal adversity is largely unknown in this birthing population. Objective: To determine the risk for severe maternal morbidity (SMM) and severe neonatal morbidity (SNM) in gestational carriers. Design: Population-based cohort study. Setting: A...

OBJECTIVES Preventive health care for children comprises routine well-child visits and immunizations. Women with physical, sensory, or intellectual or developmental disabilities tend to experience more barriers to preventive health care; yet it is unknown whether such barriers are observed among their young children. METHODS This population-based...

In this research methods tutorial of clinical anesthesia, we will explore techniques to estimate the influence of a myriad of factors on patient outcomes. Big data that contain information on patients, treated by individual anesthesiologists and surgical teams, at different hospitals, have an inherent multi-level data structure (Fig. 1). While rese...

Aims Women with gestational diabetes mellitus (GDM) have a high risk of developing type 2 diabetes (T2D). Readiness for behaviour change to mitigate this risk may be low after pregnancy and may further decrease over time without appropriate interventions. This study aimed to evaluate readiness for behaviour change in the first and second postpartum...

Introduction: In Canada, newborn morbidity far surpasses mortality. The neonatal adverse outcome indicator (NAOI) summarizes neonatal morbidity, but Canadian trend data are lacking. Methods: This Canada-wide retrospective cross-sectional study included hospital livebirths between 24 and 42 weeks' gestation, from 2013 to 2022. Data were obtained...

Objective To assess whether procedural‐induced abortion or provider‐initiated preterm delivery are associated with improved survival in pregnant people with cancer. Design Retrospective population‐based cohort study. Setting Provinces of Alberta and Ontario, Canada, 2003–2016. Population Females aged 18–50 years diagnosed with cancer at <20 week...

Background: Hypertensive disorders of pregnancy (HDP) are a leading cause of severe maternal morbidity (SMM). We sought to explore trends in HDP and related morbidity outcomes in Canada. Methods: In this retrospective population-based study, we used hospital discharge data from Canada, excluding Quebec, to identify females who had an HDP diagnos...

Objective To determine the impact of prior gestational diabetes mellitus (GDM) on perinatal outcomes in a subsequent GDM pregnancy. Methods This retrospective cohort study included 544 multiparous patients with two consecutive pregnancies between 2012‐2019, where the second (index) pregnancy was affected by GDM. The primary exposure was prior GDM...

Background: Individuals with disabilities may require specific medications in pregnancy. The prevalence and patterns of medication use, overall and for medications with known teratogenic risks, are largely unknown. Methods: This population-based cohort study in Ontario, Canada, 2004-2021, comprised all recognized pregnancies among individuals eligi...

Clinical discoveries largely depend on dedicated clinicians and scientists to identify and pursue unique and unusual clinical encounters with patients and communicate these through case reports and case series. This process has remained essentially unchanged throughout the history of modern medicine. However, these traditional methods are inefficie...

Background Contemporary estimates of diabetes mellitus (DM) rates in pregnancy are lacking in Canada. Accordingly, this study examined trends in the rates of type 1 (T1DM), type 2 (T2DM) and gestational (GDM) DM in Canada over a 15-year period, and selected adverse pregnancy outcomes. Methods This study used repeated cross-sectional data from the...

(Abstracted from Am J Obstet Gynecol 2023;229:545.e1–545.e11 Severe maternal morbidity (SMM) is a composite outcome that encompasses life-threatening maternal complications and eclampsia around the time of delivery and up to 42 days after birth. It is associated with a higher incidence of cardiovascular disease and all-cause mortality long-term, be...

Importance Severe maternal morbidity (SMM) can have long-term health consequences for the affected mother. The association between SMM and future maternal mental health conditions has not been well studied. Objective To assess the association between SMM in the first recorded birth and the risk of hospitalization or emergency department (ED) visit...

Importance A publicly funded fertility program was introduced in Ontario, Canada, in 2015 to increase access to fertility treatment. For in vitro fertilization (IVF), the program mandated an elective single-embryo transfer (eSET) policy. However, ovulation induction and intrauterine insemination (OI/IUI)—2 other common forms of fertility treatment—...

Importance Emergency department (ED) use postpartum is a common and often-preventable event. Unlike traditional obstetrics models, the Ontario midwifery model offers early care postpartum. Objective To assess whether postpartum ED use differs between women who received perinatal care in midwifery-model care vs in traditional obstetrics-model care....

Importance Unintentional injury, suicide, and homicide are leading causes of death among young females. Teen pregnancy may be a marker of adverse life experiences. Objective To evaluate the risk of premature mortality from 12 years of age onward in association with number of teen pregnancies and age at pregnancy. Design, Setting, and Participants...

Background During pregnancy, various maternal IgG antibodies are transferred to the developing fetus, some of which may protect the newborn against infection. If a mother and her fetus have different ABO blood groups, then transferred maternal antibodies may plausibly protect the infant against infection. Aim To determine if maternal-newborn ABO b...

Objective: To compare the interpregnancy weight gain in women whose first infant had a major congenital anomaly vs. those without an affected child. Design: Nationwide cohort study Setting: Denmark Population: All primigravid women with two consecutive singleton births between January 2004 and December 2017. Main Outcome Measure: Inter-pregnancy we...

Background Autism spectrum disorder (ASD) is a neurodevelopmental condition that manifests in early childhood, in which the maternal metabolic syndrome may be a risk factor. The kidney is a barometer of maternal metabolic syndrome duration and severity. Objective The main objective of this study is to determine whether periconceptional kidney func...

Objective Mothers whose newborn experiences adversity may neglect their own health to care for their affected infant or following a perinatal death. Weight gain after pregnancy is one measure of maternal self‐care. We measured interpregnancy weight gain among women whose child had an adverse perinatal event. Methods This population‐based observati...

Objective To evaluate the risk of miscarriage following SARS‐CoV‐2 vaccination, while accounting for the competing risk of induced abortion. Design Population‐based cohort study. Setting Ontario, Canada. Participants Women aged 15–50 years with a confirmed pregnancy at ≤19 completed weeks’ gestation. Methods Exposure to first SARS‐CoV‐2 vaccina...

Background Persons with non-O and Rh-positive blood types are purported to be more susceptible to infection, including SARS-CoV-2, but there remains uncertainty about the degree to which this is so for both non-viral and viral infections. Methods We systematically reviewed Embase and PubMed from January 1st 1960 to May 31st 2022. English-language...

Importance Previous studies on the risk of childhood autism spectrum disorder (ASD) following fertility treatment did not account for the infertility itself or the mediating effect of obstetrical and neonatal factors. Objective To assess the association between infertility and its treatments on the risk of ASD and the mediating effect of selected...

(Abstracted from JAMA Network Open 2023;6(5):e2315301) Women of low socioeconomic position are more likely to have poorer pregnancy outcomes than those of higher socioeconomic position, according to a growing body of epidemiological studies. Residence in low socioeconomic areas is associated with limited availability, access, and quality of health...

Background Adults with multiple chronic conditions (MCC) are a heterogeneous population with elevated risk of future adverse health outcomes. Yet, despite the increasing prevalence of MCC globally, data about MCC in pregnancy are scarce. Objectives To estimate the population prevalence of MCC in pregnancy and determine whether certain types of chr...

Background: Maternal serum markers used for trisomy 21 screening are associated with placenta-mediated complications. Recently, there has been a transition from the traditional first-trimester screening (FTS) that included PAPP-A (pregnancy-associated plasma protein-A) and beta-hCG (human chorionic gonadotropin), to the enhanced FTS test, which ad...

Background: Low-dose aspirin prophylaxis is recommended for women at risk of preeclampsia. Capturing aspirin prophylaxis within administrative databases can be challenging since it is an over-the-counter medication. The Better Outcome Registry and Network (BORN) database, a perinatal health registry in Ontario, Canada, includes a formal variable t...

Background: Oxycodone is increasingly prescribed for postpartum analgesia in lieu of codeine owing to concerns regarding the neonatal safety of codeine during lactation. We examined whether initiation of oxycodone after delivery was associated with an increased risk of persistent opioid use relative to initiation of codeine. Methods: We conducte...

Maternal mortality is the death of a woman while pregnant or within 42 days of the end of pregnancy. Late maternal deaths are from 42 to 365 days thereafter. Maternal mortality is an important surrogate indicator of a woman's overall health, social and economic status, and the provision of antenatal and emergency obstetric care at regional and nati...

Objectives To quantify well-child visits by age 2 years and developmental screening at the 18-month enhanced well-child visit among children with prenatal opioid exposure (POE) and to identify factors associated with study outcomes. Design Population-based cohort study. Setting Ontario, Canada. Participants 22 276 children with POE born 2014–201...

Background: Severe maternal morbidity is a composite indicator of maternal health and obstetrical care. Little is known about the risk of recurrent severe maternal morbidity in a subsequent delivery. Objective: To estimate the risk of recurrent severe maternal morbidity in the next delivery after a complicated first delivery. Study design: We...

Aims: To examine the influence of immigration status and region of origin on the risk of type 2 diabetes in women with prior gestational diabetes (GDM). Methods: This retrospective population-based cohort study included women with gestational diabetes (GDM) aged 16 to 50 years in Ontario, Canada who gave birth between 2006-2014. We compared the...

Importance: Residing in a low-income neighborhood is generally associated with worse pregnancy outcomes. It is not known if moving from a low- to higher-income area between 2 pregnancies alters the risk of adverse birth outcomes in the subsequent birth compared with women who remain in low-income areas for both births. Objective: To compare the...

Background: Living in low-income neighbourhoods and being an immigrant are each independently associated with adverse neonatal outcomes, but it is unknown if disparities exist in the neonatal period for children of immigrant and nonimmigrant females living in low-income areas. We sought to compare the risk of severe neonatal morbidity and mortalit...

Importance: Outcomes among patients with pregnancy-associated cancers (diagnosed during pregnancy or 1-year postpartum) other than breast cancer have received relatively little research attention. High-quality data from additional cancer sites are needed to inform the care of this unique group of patients. Objective: To assess mortality and surv...

Background: Canada has 2 main streams of resettlement: government-assisted refugees and privately sponsored refugees, whereby citizens can privately sponsor refugees and provide resettlement services, including health care navigation. Our objective was to compare receipt of adequate prenatal care among privately sponsored and government-assisted r...

Background: Pregnancy and the postpartum period are a high-risk time for venous thromboembolism (VTE). Decreased mobility is also a major risk factor. Yet, the risk of peri-pregnancy VTE among individuals with physical disabilities is unknown. Objective: To compare the risk of peri-pregnancy VTE in people with and without a physical disability....

Objectives Clinical discoveries are heralded by observing unique and unusual clinical cases. The effort of identifying such cases rests on the shoulders of busy clinicians. We assess the feasibility and applicability of an augmented intelligence framework to accelerate the rate of clinical discovery in preeclampsia and hypertensive disorders of pre...

Background Preeclampsia is a leading cause of maternal and perinatal mortality and morbidity. The management of preeclampsia has not changed much in more than two decades, and its aetiology is still not fully understood. Case reports and case series have traditionally been used to communicate new knowledge about existing conditions. Whether this is...

Objective To examine whether maternal opioid treatment after delivery is associated with an increased risk of adverse infant outcomes. Design Population based cohort study. Setting Ontario, Canada. Participants 865 691 mother-infant pairs discharged from hospital alive within seven days of delivery from 1 September 2012 to 31 March 2020. Each mo...

Background: Schizophrenia is associated with increased risk of experiencing interpersonal violence. Little is known about risk specifically around the time of pregnancy. Methods: This population-based cohort study included all individuals (aged 15–49 yr) listed as female on their health cards who had a singleton birth in Ontario, Canada, between 2...

Objective: To compare well-baby visit and vaccination schedule adherence up to age 24 months in children of mothers with versus without schizophrenia. Methods: Using administrative health data on births in Ontario, Canada (2012-2016), children of mothers with schizophrenia (ICD-9: 295; ICD-10: F20/F25; DSM-IV schizophrenia or schizoaffective disord...

Importance: Maternal emergency department (ED) use before or during pregnancy is associated with worse obstetrical outcomes, for reasons including preexisting medical conditions and challenges in accessing health care. It is not known whether maternal prepregnancy ED use is associated with higher use of the ED by their infant. Objective: To stud...

This study determined the accuracy of first trimester serum Human Chorionic Gonadotrophin (HCG) for estimating gestational age (GA). We included 273,584 singleton livebirths that had a first trimester ultrasound and measured serum HCG at 4-12 weeks gestation in XXX from 2012-2018. We estimated HCG accuracy compared to known GA, within a boundary of...

Background: Pregnancy increases a woman's susceptibility to severe COVID-19, especially those with metabolic dysfunction. It is unknown if markers of metabolic dysfunction commonly assessed around pregnancy are associated with COVID-19 illness after pregnancy. Aim: The aim of this study is to evaluate the indicators of metabolic dysfunction coll...

Importance: Evidence indicates that immigrant women and women residing within low-income neighborhoods experience higher adversity during pregnancy. Little is known about the comparative risk of severe maternal morbidity or mortality (SMM-M) among immigrant vs nonimmigrant women living in low-income areas. Objective: To compare the risk of SMM-M...

Background: CKD is a risk factor for pregnancy complications, but estimates for adverse outcomes come largely from single-center studies with few women with moderate or advanced stage CKD. Methods: To investigate the association between maternal baseline eGFR and risk of adverse pregnancy outcomes, we conducted a retrospective, population-based...

Introduction Gestational diabetes mellitus (GDM) is associated with adverse perinatal outcomes. Approaches to screening for GDM continue to evolve, introducing potential variability of care. This study explored the impact of these variations on GDM counselling and screening from the perspectives of pregnant individuals. Methods Following a Corbin...

Twin pregnancy is a risk factor for postpartum depression and anxiety. Whether this translates into a higher risk of severe maternal mental illness in the short-term or long-term is unknown. This study was a population-based retrospective cohort study, using linked health administrative databases for the entire province of Ontario, Canada. Included...

Background: Prior studies comparing first-trimester pharmaceutical induced abortion (IA) with procedural IA were prone to selection bias, were underpowered to assess serious adverse events (SAEs), and did not account for confounding by indication. Starting in 2017, mifepristone-misoprostol was dispensed at no cost in outpatient pharmacies across O...

Background Breastfeeding provides infants with nutrients required for optimal growth and development. We aimed to examine breastfeeding practices and supports that promote exclusive breastfeeding during the birth hospital stay among birthing parents with physical disabilities, sensory disabilities, intellectual or developmental disabilities, and mu...

Introduction: Women with a history of pre-eclampsia are at higher risk of premature coronary artery disease. Assessment of obstructive coronary artery stenosis by invasive coronary angiography has not been evaluated after pre-eclampsia. Methods: A population-based cohort study was completed in Ontario, Canada, where there is universal healthcare...

Objective: To compare the risk of interpersonal violence experienced by pregnant and postpartum individuals with physical disabilities, sensory disabilities, or intellectual or developmental disabilities with those without disabilities, and to examine whether a prepregnancy history of interpersonal violence puts individuals with disabilities, at e...

Aims: As an indicator of maternal cardio-metabolic health, newborn birthweight may be an important predictor of maternal type 2 diabetes mellitus (diabetes). We evaluated the relation between offspring birthweight and onset of maternal diabetes after pregnancy. Methods: This retrospective cohort study used linked population-based health database...

Importance: Emergency department (ED) use during pregnancy may be associated with worse obstetrical outcomes, possibly because of differences in access to health care. It is not known whether ED use before pregnancy is associated with serious adverse maternal and perinatal outcomes. Objective: To study the association between prepregnancy ED use...

BACKGROUND : Both gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) are common, and each are associated with adverse maternal and perinatal outcomes. Midwives may be the first point of care when these conditions arise. This study evaluated the experiences of midwives when providing care to women and people with pregn...

Objective To study the association between mode of conception and risk of preterm birth, including, spontaneous and provider-initiated subtypes. Design Population-based retrospective cohort study. Setting Not applicable. Patients All singleton livebirths and stillbirth in Ontario, Canada, 2006–2014. Intervention The main exposure was mode of co...

OBJECTIVES To assess the risk of neonatal complications among women with a disability. METHODS This population-based cohort study comprised all hospital singleton livebirths in Ontario, Canada from 2003 to 2018. Newborns of women with a physical (N = 144 187), sensory (N = 44 988), intellectual or developmental (N = 2207), or ≥2 disabilities (N =...

Purpose To examine the risk of perinatal mental illness, including new-onset disorders and recurrent or ongoing use of mental health care, comparing women with physical, sensory, intellectual/developmental, and multiple disabilities to those without a disability. Methods From all women aged 15–49 years with a singleton birth in Ontario, Canada (20...