Dan Farine

University of Toronto, Toronto, Ontario, Canada

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Publications (169)575.57 Total impact

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    ABSTRACT: Objective To assess the impact of body mass index (BMI) on the rate of cesarean section (rCS) in induction of labor (IOL). Study Design A total of 7,543 singleton term pregnancies undergoing IOL (cervical dilatation at admission, CDA ≤ 3 cm) were divided according to BMI: underweight (n = 325); normal weight (NW) (n = 4,633); overweight (OW) (n = 1,610); and obese (n = 975). Age, parity, macrosomia, gestational age (GA), gestational weight gain (GWG), CDA, and IOL indications were considered. Results A higher rate of macrosomia (15.0 vs. 11.1%; p < 0.0001), earlier induction (GA 39.7 ± 1.3 vs. 40.1 ± 1.3 weeks; p < 0.0001) for maternal indications (39.1 vs. 21.1%; p < 0.001), and lower CDA (≤1cm; 66.4 vs. 61.4%; p < 0.005) were observed in obese versus NW. The rate of weight gain above the recommended range was higher in obese (obese 70.6% vs. NW 43.9%; p < 0.001), despite a significantly lower mean GWG compared with NW (14 ± 7.5 vs. 16.5 ± 5.6 kg; p < 0.001). Compared with NW, OW and obese demonstrated a significantly higher rCS (OW 31.1% and obese 36.9% vs. NW 24.7%; p < 0.001). BMI represented an independent factor affecting the rCS (vs. NW; OW odds ratio [OR] 1.4; confidence interval [CI] 1.2-1.7; p < 0.001; obese OR 2.3; CI 1.9-2.7 p < 0.001). Conclusion In the case of IOL, obesity represents an independent factor associated with a significant increase of CS to be considered during induction counselling.
    No preview · Article · Sep 2015 · American Journal of Perinatology

  • No preview · Article · Jun 2015
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    ABSTRACT: Objective: Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient. Outcomes: Significant health and economic outcomes considered in comparing alternative practices. Evidence: Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values: The 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). Benefits, harms, and costs: This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma. Summary Statement Specific traumatic injuries At this time, there is insufficient evidence to support the practice of disabling air bags for pregnant women. (III) Recommendations Primary survey 1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C) 2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content. (III-C) 3. Oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation. (II-1B) 4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C) 5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman. (III-C) 6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B) 7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt. (II-1B) 8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available. (I-A) 9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility 10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B) 11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries. (III-C) Evaluation of a pregnant trauma patient in the emergency room 12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible. (II-3B) 13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended. (II-3B) 14. In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan. (III-C) Adjunctive tests for maternal assessment 15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation. (II-2B) 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. (III-C) 17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen. (III-C) 18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients. (II-3B) 19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected. (III-C) Fetal assessment 20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. (II-3B) 21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (> 1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen < 200 mg/dL should be admitted for observation for 24 hours. (III-B) 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients. (III-B) 23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin. (III-B) 24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated. (III-C) 25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital. (III-C) 26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes. (III-C) Obstetrical complications of trauma 27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis. (II-3D) Specific traumatic injuries 28. Tetanus vaccination is safe in pregnancy and should be given when indicated. (II-3B) 29. Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence. (II-3B) 30. During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times. (II-2B) Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B).
    No preview · Article · Jun 2015 · Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC
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    ABSTRACT: Child outcomes associated with severe maternal nausea and vomiting of pregnancy are understudied. The study objective was to determine child long-term neurodevelopment after maternal hospitalization for severe nausea and vomiting of pregnancy. Motherisk NVP Helpline callers from 2006 to 2012 were identified from our prospectively collected database. Women with nausea and vomiting of pregnancy treated with doxylamine-pyridoxine (Diclectin/Diclegis) or with no pharmacotherapy were included. Diclectin/Diclegis dose, severity of nausea and vomiting of pregnancy, hospitalization for nausea and vomiting of pregnancy, concomitant medications, severity of maternal depression, and maternal intelligence quotient (IQ) were obtained. Children (ages 3 6/12 to 6 11/12 years) were assessed using standardized psychological tests. The study cohort was divided into three groups: 1) nausea and vomiting of pregnancy treated with more than four tablets per day of Diclectin/Diclegis (above the manufacturer-recommended number of tablets) (n=62); 2) nausea and vomiting of pregnancy treated with the recommended up to four tablets per day (n=81); and 3) nausea and vomiting of pregnancy and no pharmacotherapy (n=76). Twenty-two women were hospitalized for severe nausea and vomiting of pregnancy. The hospitalized women initiated recommended preventive antiemetics significantly later (6.8 compared with 5.7 weeks, P=.02), experienced more severe nausea and vomiting of pregnancy (11.1 compared with 7.5, P<.001), and depression (10.1 compared with 5.1, P=.03) and needed higher daily doses of Diclectin/Diclegis (1.0 compared with 0.4 mg/kg per day, P<.001) and concomitant medications. Children of hospitalized mothers achieved significantly lower IQ scores (verbal 107.2 compared with 112.7, P=.04; performance 105.6 compared with 112.3, P=.03; full scale 108.7 compared with 114.2, P=.05). Duration of hospitalization, maternal depression, and maternal IQ were significant predictors for these outcomes. Daily intake of Diclectin/Diclegis was not associated with any adverse outcomes. Timely preventive antiemetics and depression control may prevent hospitalization and be associated with favorable child neurodevelopment. More research is needed to investigate the effect of severe nausea and vomiting of pregnancy and confirm these results.
    No preview · Article · May 2015 · Obstetrics and Gynecology
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    ABSTRACT: Hyperemesis gravidarum affects up to 2% of pregnant women and is associated with adverse pregnancy outcomes. The effects of intensive counseling in these women are understudied. Prospectively collected cohort of women who called the Motherisk Nausea and Vomiting of Pregnancy Helpline for symptom management counseling was included. The study group consisted of women with hyperemesis gravidarum and the control group consisted of women with varying degrees of nausea and vomiting of pregnancy severity. Both groups received counseling on dietary changes, pharmacotherapy, and psychological support. Statistical analysis included inferential statistics, correlations, and regression. The women with hyperemesis gravidarum (n=240) required and sought more counseling compared with the control group (n=290). The women with hyperemesis gravidarum were younger (30.8 compared with 32.6 years; P<.001), called in for counseling significantly later (13.4 compared with 8.7 weeks of gestation; P<.001), and experienced more prolonged and severe nausea and vomiting of pregnancy (31 compared with 27 weeks of gestation; P<.001). There were no differences in the duration of gestation, birth weight, or perinatal complications. The women with hyperemesis gravidarum breastfed longer (11.2 compared with 8.5 months; P=.02), and their infants reached their developmental milestones significantly earlier (crawling [7.9 compared with 8.4 months; P=.03], speech [9.9 compared with 11.7; P<.001], sitting unaided [5.9 compared with 6.3 months; P=.02]). The number of counseling sessions per week was a significant predictor for maternal weight gain (P=.001). However, the severity of nausea and vomiting of pregnancy was a significant predictor for duration of gestation and child speech development (P=.02 and P=.01, respectively). Timely provided counseling, balanced nutrition, pharmacotherapy, and emotional support were associated were more favorable outcomes in patients with hyperemesis gravidarum. More research is needed to study the relationship between the severity of nausea and vomiting of pregnancy and a child's developmental milestones.
    No preview · Article · May 2015 · Obstetrics and Gynecology
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    ABSTRACT: Purpose: The aim of this study was to estimate the effective dose 90% (ED90) of carbetocin to provide adequate uterine tone at Cesarean delivery (CD) for labour arrest. Methods: We conducted a double-blind dose-finding study of carbetocin using a biased-coin up-and-down design in women undergoing CD for labour arrest under epidural anesthesia. Forty healthy term pregnant women who had received at least three hours of oxytocin infusion during labour were recruited for the study. Carbetocin was administered intravenously upon delivery of the anterior shoulder of the fetus. The first patient received 20 µg, and the dose for the subsequent patient was determined according to the response of the previous patient as per the biased-coin allocation scheme using increments or decrements of 20 µg (maximum 140 µg). Uterine tone was assessed by the obstetrician and rated as satisfactory or unsatisfactory throughout the intraoperative period. The primary outcome was satisfactory uterine tone with no need for additional uterotonic drugs intraoperatively. Secondary outcomes included use of additional uterotonic drugs postoperatively in the first 24 hr, estimated blood loss, and adverse effects. Results: The ED90 of carbetocin to produce adequate uterine tone was estimated at 121 µg (95% confidence interval [CI]: 111 to 130; 99% CI: 108 to 133) using the truncated Dixon and Mood (DM) method. The isotonic estimator of ED90 was 140 µg; however, the observed response rate across all doses was < 90%. Also, the 95% CI of the DM estimator is likely to have lower than expected coverage, while the 99% CI may have about 90% coverage. Therefore, these results should be interpreted with caution. The overall median (range) estimated blood loss was 1,014 (104-2,436) mL. The overall incidence of hypotension and tachycardia were 45% and 57.5%, respectively. At a dose of 140 µg, the incidence of tachycardia and intraoperative arrhythmias was 76% and 14%, respectively. Conclusion: The ED90 of carbetocin at CD for labour arrest, as determined in our study, should be interpreted with caution since it may be underestimated. This dose is higher than the currently recommended dose of 100 µg at elective CD and should not be used routinely given the uncertainty regarding its efficacy and the high incidence of arrhythmias at higher doses. This trial was registered at ClinicalTrials.gov, number: NCT01725243.
    No preview · Article · Apr 2015 · Canadian Anaesthetists? Society Journal
  • Nguyen-Lu N · Carvalho JC · Farine D · Seaward G · Ye XY · Balki M.
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    ABSTRACT: Abstract PURPOSE: The aim of this study was to estimate the effective dose 90% (ED90) of carbetocin to provide adequate uterine tone at Cesarean delivery (CD) for labour arrest. METHODS: We conducted a double-blind dose-finding study of carbetocin using a biased-coin up-and-down design in women undergoing CD for labour arrest under epidural anesthesia. Forty healthy term pregnant women who had received at least three hours of oxytocin infusion during labour were recruited for the study. Carbetocin was administered intravenously upon delivery of the anterior shoulder of the fetus. The first patient received 20 µg, and the dose for the subsequent patient was determined according to the response of the previous patient as per the biased-coin allocation scheme using increments or decrements of 20 µg (maximum 140 µg). Uterine tone was assessed by the obstetrician and rated as satisfactory or unsatisfactory throughout the intraoperative period. The primary outcome was satisfactory uterine tone with no need for additional uterotonic drugs intraoperatively. Secondary outcomes included use of additional uterotonic drugs postoperatively in the first 24 hr, estimated blood loss, and adverse effects. RESULTS: The ED90 of carbetocin to produce adequate uterine tone was estimated at 121 µg (95% confidence interval [CI]: 111 to 130; 99% CI: 108 to 133) using the truncated Dixon and Mood (DM) method. The isotonic estimator of ED90 was 140 µg; however, the observed response rate across all doses was < 90%. Also, the 95% CI of the DM estimator is likely to have lower than expected coverage, while the 99% CI may have about 90% coverage. Therefore, these results should be interpreted with caution. The overall median (range) estimated blood loss was 1,014 (104-2,436) mL. The overall incidence of hypotension and tachycardia were 45% and 57.5%, respectively. At a dose of 140 µg, the incidence of tachycardia and intraoperative arrhythmias was 76% and 14%, respectively. CONCLUSION: The ED90 of carbetocin at CD for labour arrest, as determined in our study, should be interpreted with caution since it may be underestimated. This dose is higher than the currently recommended dose of 100 µg at elective CD and should not be used routinely given the uncertainty regarding its efficacy and the high incidence of arrhythmias at higher doses. This trial was registered at ClinicalTrials.gov, number: NCT01725243.
    No preview · Article · Apr 2015 · Canadian Journal of Anaesthesia

  • No preview · Article · Jan 2015 · American Journal of Obstetrics and Gynecology
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    ABSTRACT: To determine the interventions utilized by Maternal Fetal Medicine specialists in the prediction and prevention of preterm labour in higher order multiple gestations. Survey Monkey® questionnaires and email surveys were sent to all the Maternal Fetal Medicine (MFM) specialists in Canada (n=122). Questionnaire items included interventions physicians routinely recommended for HOM gestations including: (1) Bed rest (2) Cervical length measurement on transvaginal ultrasound (3) Corticosteroids use (4) Cerclage and (5) Tocolytic therapy. Response rate was 66% (81/122), with 68% of respondents in practice for over 10 years. 91% of physicians did not routinely recommend bed rest (95%CI, 84.7-97.2). 82 % (95% CI, 73.63-90.4%) recommended routine cervical length assessment with 32.3% (95% CI, 20.7-43.2) and 37.1% (95% CI, 25.3-48.6) of this group suggesting assessment at 16-18 and 19-21 weeks respectively. Frequency of assessment varied from biweekly (53.3% [95% CI, 40.9-65.0]), to monthly (23.3% [95% CI, 12.8-33.1]), to a single measurement repeated only if abnormal (12.5% [95% CI 4.5-20.8). 28% (95% CI, 18.2-37.8) recommended routine administration of corticosteroids for lung maturation. Timing of administration varied, with 24% initiating steroids between 24-26weeks, 59% between 27-28weeks, and 17% after 28 weeks. None reported routine cerclage placement. However, 71% (95% CI, 61.1- 80.8) would perform cerclage based on history or ultrasound. 81% (95% CI, 72.4-89.5) of respondents would consider using tocolytic agents for threatened preterm labor (TPTL) including calcium channel blockers (94%), NSAIDs (5%), and nitro-patch (24%). The variable practice guidelines and paucity of data for management of high order multiple pregnancy, places the onus on individual practitioners to develop their own management schemes. This results in heterogeneous management, which is based on conflicting international guidelines, studies, expert opinion or past experience. Copyright © 2014 Elsevier Inc. All rights reserved.
    No preview · Article · Dec 2014 · American Journal of Obstetrics and Gynecology
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    ABSTRACT: Most bioequivalence studies are conducted in males, even for drugs aimed exclusively for women, assuming that bioequivalence variability is similar between sexes. To examine this assumption, we compared the bioequivalence and pharmacokinetics of Diclectin and Diclegis (doxylamine-pyridoxine combination), exclusively aimed at nausea and vomiting of pregnancy, between health young men and women. A single dose (2×10-10 mg) bioavailability study. Healthy young males (n=12) and nonpregnant females (n=12). After a 21-day washout, dose administration and blood sampling were repeated. Doxylamine, pyridoxine, and its metabolites were measured. Differences in pharmacokinetic parameters and their variances between males and females were assessed. Females had significantly larger area under the curve at time 0 for doxylamine (1,550.0 ng*hr/mL±289.8 compared with 1,272.4 ng*hr/mL±265.1) (P=.001) and pyridoxine (35.2 ng*hr/mL±15.3 compared with 25.2 ng*hr/mL±7.8) (P=.006) compared with males. Males (2,352 ng*hr/mL±513) had a significantly larger area under the curve at time 0 for pyridoxal-5'-phosphate (1726 ng*hr/mL±603) (P<.001). A higher maximum concentration for doxylamine was observed in females (106.9 ng/mL±17.1 compared with 86.3 ng/mL±13.2) (P<.001). The maximum concentration for pyridoxal-5'-phosphate was higher in males (49.3 ng/mL±9.8) compared with females (41.0 ng/mL±16.2) (P=.037). Bioequivalence variability of doxylamine, pyridoxine, and pyridoxal-5'-phosphate was different between the sexes. As a result of pharmacokinetic differences, large variability, and lack of bioequivalence between sexes, our results support the claim that bioequivalence of drugs aimed for women should not be conducted in males, because they are clinically irrelevant in predicting clinical reality.
    No preview · Article · May 2014 · Obstetrics and Gynecology
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    ABSTRACT: Nausea and vomiting of pregnancy is the most common condition during gestation. Over the last 30 years, there has not been a U.S. Food and Drug Administration (FDA)-approved antiemetic for nausea and vomiting of pregnancy. The objective of this study was to provide information on the pattern of antiemetic use among American women calling Motherisk NVP Helpline in Toronto, the only such service worldwide. We reviewed the intake forms of American women calling the Helpline in the past 10 years. Clinical and demographic data with details on nausea and vomiting of pregnancy treatment, nausea and vomiting of pregnancy symptoms, and concomitant medical conditions were extracted. A total of 522 women were included in the study. A total of 10.3% of the women had mild, 77.7% had moderate, and 12% had severe nausea and vomiting of pregnancy. A total of 15.5% had hyperemesis gravidarum. Of all women, 28% did not receive any antiemetic although 71.4% of them had moderate and 12.9% had severe nausea and vomiting of pregnancy. A total of 42.3% was treated with one antiemetic drug, 17.2% with two, 9% with three, and 3.4% took four or more. Doxylamine was used by 57.7% of the treated women, 55.9% used ondansetron, 35.7% used other antihistamines, and 13.8% used metoclopramide. The most frequent monotherapy was doxylamine (48%) followed by ondansetron (39%). Women receiving two antiemetic drugs were mostly on a combination of ondansetron and doxylamine (35.6%), ondansetron and another antiemetic (31.1%), and doxylamine with another antiemetic (20%). The lack of a FDA-approved drug for nausea and vomiting of pregnancy has led American women to be treated suboptimally. Since the FDA approval of the doxylamine-pyridoxine combination (Diclegis), both physicians and women will gain more confidence in a safe and effective option.
    No preview · Article · May 2014 · Obstetrics and Gynecology
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    ABSTRACT: Nausea and vomiting of pregnancy affect up to 90% of all pregnancies. Diclectin and Diclegis (delayed-release 10 mg doxylamine-10 mg pyridoxine combination) is the only antiemetic approved in the United States and Canada for nausea and vomiting of pregnancy at a maximum dose of 4 tablets per day. However, some women receive off-label higher doses, up to 12 tablets per day. The objective of this study was to assess long-term neurodevelopmental fetal safety of this drug combination. We compared the neurocognitive development of children from four mother-child groups: 1) nausea and vomiting of pregnancy treated with more than four tablets of Diclectin (n=41); 2) nausea and vomiting of pregnancy treated with up to four tablets per day of Diclectin (n=84); 3) nausea and vomiting of pregnancy and no treatment (n=63); and 4) no nausea and vomiting of pregnancy (n=49). Children received a full age-appropriate psychological assessment at 3-7 years of age. Children of all four groups scored in the normal range for IQ, language, temperament, and behavior. The children whose mothers experienced nausea and vomiting of pregnancy achieved significantly higher scores on some subscales of cognition, language, and behavior, correlating with the severity of the nausea and vomiting of pregnancy. The Diclectin-exposed groups scored significantly higher on a small number of subtests, but none of the differences could be considered clinically significant and no dose-dependent effects were observed. Diclectin does not appear to harm neurodevelopment even at off-label supradoses and should be considered safe for the treatment of nausea and vomiting of pregnancy. The severity of nausea and vomiting of pregnancy correlates positively with neurodevelopmental achievements.
    No preview · Article · May 2014 · Obstetrics and Gynecology
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    ABSTRACT: To obtain quantitative data on uterine contractility postpartum and compare the response of intramuscular oxytocin to carbetocin. A prospective study using an intrauterine pressure transducer (IUPT) to measure frequency, amplitude, and duration of contractions following the administration of either oxytocin (10 U) or carbetocin (30 microg). The IUPT was tolerated by all subjects and generated useful data 90% of the time in most subjects (12/16). Both drugs generated hypertonic uterine activity with contractions of similar duration. However, carbetocin resulted in contractions of sustained higher amplitude and frequency and therefore higher uterine performance as expressed by Montevideo units. This uterotonic effect of carbetocin lasted for 3 hours. IUPT monitoring generated quantitative data on postpartum uterine activity. When compared to high-dose oxytocin, a low dose of carbetocin has a more prolonged effect on uterine activity both in terms of a higher amplitude and frequency of contractions.
    No preview · Article · Apr 2014 · The Journal of reproductive medicine
  • Mary Higgins · Dan Farine
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    ABSTRACT: Worldwide, the rate of delivery by cesarean section is increasing, such that the cesarean section rate is often greater than 30%. The reasons for this increase are many, but a major reason for this change is related to our relatively poor ability to manage labor. This review attempts to cover the issues that contribute to this. Issues regarding definition, assessment and management of labor progress as well as critical times in labor will be examined. Types of partograms are discussed as well as the maternal and fetal factors that influence progress of labor. To be able to care for women in labor, it is important to be aware of limitations of management and how best to overcome these.
    No preview · Article · Jan 2014 · Expert Review of Obstetrics & Gynecology
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    ABSTRACT: The purpose of this study was to determine the intravenous dose of carbetocin required to produce effective uterine contraction in 90% of females (ED90) undergoing elective Cesarean delivery (CD) under spinal anesthesia. We conducted a double-blind dose-finding study of carbetocin. Forty females undergoing elective CD received carbetocin intravenously upon delivery of the fetus. The dose of carbetocin for each patient was determined according to a biased-coin up-and-down sequential allocation scheme designed to cluster doses close to ED90. The initial dose was 10 μg, with increments/decrements of 5 μg. The anesthesiologist, obstetrician, and patient were blinded to the dose. The obstetrician assessed the uterine tone at one-minute intervals for five minutes after carbetocin administration. In case of unsatisfactory tone, additional uterotonics were administered. The primary outcome was requirement for additional intraoperative uterotonics. Secondary outcomes were postoperative requirement for additional uterotonics within 24 hr of delivery, estimated blood loss and side effects. The ED90 of carbetocin was 14.8 μg (95% confidence interval 13.7 to 15.8). Thirty-seven patients (92.5%) had adequate uterine tone with no requirement of additional intraoperative uterotonics. Two patients (5%) required postoperative uterotonics within 24 hr. The overall mean (SD) estimated blood loss was 786 (403) mL and the overall incidence of hypotension (decrease in systolic blood pressure ≥ 20% baseline) was 37.5%. Based on our study, the ED90 of carbetocin at elective CD is less than one-fifth the currently recommended dose of 100 μg. This study was registered at clinicaltrials.gov (NCT-01651130).
    No preview · Article · Nov 2013 · Canadian Anaesthetists? Society Journal
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    ABSTRACT: The aim of this study was to determine the intravenous dose of carbetocin required to produce effective uterine contraction in 95% of women (ED95) undergoing elective Cesarean delivery under spinal anesthesia. One hundred and twenty term pregnant women at low risk for postpartum hemorrhage (PPH) undergoing elective Cesarean delivery under spinal anesthesia were randomly allocated to receive carbetocin in doses of 20, 40, 60, 80, or 100 μg iv upon delivery of the fetus. The obstetrician evaluated the efficacy of uterine tone as satisfactory or unsatisfactory, and in case of unsatisfactory tone, additional uterotonics were administered as per routine institutional practice. The primary outcome measure was satisfactory uterine tone at two minutes after carbetocin administration, and the secondary outcomes were the estimated blood loss, need for additional uterotonic agents within 24 hr, and side effects. Overall satisfactory uterine tone at two minutes was observed in 94.2% (113/120) of the women, and there was no difference across the different study groups. It was not possible to calculate the ED95 of carbetocin due to the even distribution of women with unsatisfactory uterine tone at two minutes across all dose groups (P = 0.60). Additional uterotonics within 24 hr were required in 13% (16/120) of the women. Side effects were similar across all dose groups, with an overall 42.5% incidence of hypotension following the administration of carbetocin. In women at low risk for PPH undergoing elective Cesarean delivery under spinal anesthesia, carbetocin is similarly effective in doses of 20-100 μg. There is a high incidence of hypotension associated with carbetocin in these doses. Further dose-finding studies are warranted, including doses lower than 20 μg. This trial was registered at www.clinicaltrials.gov (NCT01428817).
    No preview · Article · Nov 2013 · Canadian Anaesthetists? Society Journal

  • No preview · Article · Sep 2013 · Obstetric Anesthesia Digest
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    ABSTRACT: Unlabelled: This article reviews the use and effectiveness of emergency cerclage for women who present with a dilated cervix in the second trimester of pregnancy and seeks to identify predictors of favorable emergency cerclage outcomes. We searched PubMed and the Cochrane Library for the period January 1995 to April 2012 and used the terms "emergency cerclage," "emergency stitch," "rescue cerclage," and "rescue stitch." Thirty-four studies in which transvaginal emergency cervical cerclage was performed in women with a dilated cervix were identified and included. Predictors of poor outcome were prolapsed membranes, evidence of intra-amniotic or systemic infection, symptomatic presentation, cervical dilatation greater than 3 cm, or cerclage after 22 weeks. According to observational and limited randomized controlled trials, the cerclage group did significantly better than the bed-rest group in mean randomization-to-delivery interval, preterm delivery before 34 weeks, and compound neonatal morbidity. The current data suggest that emergency cerclage is associated with a longer latency period and, most often, with better pregnancy outcomes when compared with bed rest. Many of the predictors of adverse outcomes appear to be associated with evidence of inflammation or infection. Target audience: Obstetricians and gynecologists, family physicians Learning objectives: After completing this CME activity, physicians should be better able to review the use and evaluate the effectiveness of emergency cerclage for women who present with a dilated cervix in the second trimester, to identify predictors of favorable emergency cerclage outcomes, and to compare emergency cerclage versus bed rest.
    No preview · Article · May 2013 · Obstetrical & gynecological survey
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    Full-text · Article · Apr 2013 · Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC
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    Susan Pakenham · Andrea Copeland · Dan Farine
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    ABSTRACT: Objective: To determine whether obstetrical patients in a large tertiary-care centre receive counselling, are aware of the proper actions in relation to fetal movement (on the basis of discussion with caregivers, educational pamphlet, or access to any information), have an understanding similar to that prescribed in the SOGC guidelines, and seek timely assessment in the event of decreased fetal movement. Methods: We surveyed a convenience sample of pregnant women (N = 206) at term between July and October 2011. After collecting demographic and provider information, we assessed patient familiarity with fetal movement counting, including sources, timeliness, counting protocols, and response to decreased fetal movement. We calculated incidence rates, measures of association, and statistical significance by chi-square testing. Results: The majority of patients (147/206 = 71.4%) relied on their care provider for information, and 44.1% of patients were very familiar with fetal movement counting. A majority, 57.8% (119), received timely information, although 8.1% (27) received information late in pregnancy or not at all. Quite consistently amongst subgroups (low vs. high-risk pregnancy, nullipara vs. multipara, patients of varied providers), one third (34.7%, 70/202) of patients had no knowledge or incorrect knowledge of the SOGC guidelines, 35.1% (71/202) had knowledge of fetal movement counting and what to do, while 30.2% (61/202) who knew how to monitor fetal movements did not know how to respond to decreased movement. Conclusion: Timely intervention for decreased fetal movement results in a substantial reduction in the rate of stillbirth. Only one third of our patients were both informed and would have sought further investigation for decreased movement. Reinforcing the significance of fetal movement counting in scholarly publications can remind care providers about the importance of informing all patients about this simple, inexpensive, and successful monitoring protocol.
    Preview · Article · Feb 2013 · Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC

Publication Stats

4k Citations
575.57 Total Impact Points

Institutions

  • 1992-2015
    • University of Toronto
      • • Department of Obstetrics and Gynaecology
      • • Department of Medicine
      • • Mount Sinai Hospital
      Toronto, Ontario, Canada
    • Samuel Lunenfeld Research Institute
      Toronto, Ontario, Canada
  • 1990-2015
    • Mount Sinai Hospital, Toronto
      • Department of Obstetrics and Gynecology
      Toronto, Ontario, Canada
    • Mid-Columbia Medical Center
      DLS, Oregon, United States
  • 2010
    • Kingston College
      Kingston, New York, United States
  • 2009
    • JVS Toronto
      Toronto, Ontario, Canada
  • 2008
    • Society for Maternal-Fetal Medicine
      Mount Sinai, New York, United States
  • 2003
    • University of British Columbia - Vancouver
      • Department of Obstetrics and Gynaecology
      Vancouver, British Columbia, Canada
  • 1997
    • Sunnybrook Health Sciences Centre
      • Department of Evaluative Clinical Sciences
      Toronto, Ontario, Canada
  • 1995
    • Toronto Western Hospital
      Toronto, Ontario, Canada
  • 1991
    • Women's College Hospital
      Toronto, Ontario, Canada