Joan M.G. Crane’s research while affiliated with Memorial University of Newfoundland and other places

Objectif: Mettre à jour les recommandations sur la corticothérapie prénatale dans la période de prématurité tardive. Population cible: Personnes enceintes à risque d'accouchement prématuré entre 34 SA + 0 j et 36 SA + 6 j. Options: Administrer ou non un traitement unique de corticothérapie prénatale entre 34 SA + 0 j et 36 SA + 6 j. RéSULTATS: Morbidité néonatale (détresse respiratoire, hypoglycémie), troubles neurodéveloppementaux à long terme et autres issues indésirables à long terme (retard de croissance, trouble cardiométabolique, problèmes respiratoires). BéNéFICES, RISQUES ET COûTS: La corticothérapie prénatale administrée entre 34 SA + 0 j et 36 SA + 6 j diminue le risque de morbidité respiratoire néonatale, mais augmente le risque d'hypoglycémie néonatale. Les effets à long terme de la corticothérapie prénatale administrée entre 34 SA + 0 j et 36 SA + 6 j demeurent incertains. DONNéES PROBANTES: Pour obtenir des données probantes sur les effets néonataux de l'administration d'une corticothérapie prénatale en période de prématurité tardive, les auteurs ont résumé les données de l'analyse Cochrane de 2020 sur la corticothérapie prénatale et ont combiné ces données à celles des essais randomisés répertoriés par une recherche dans la base de données Ovid MEDLINE pour les articles publiés entre le 1er janvier 2020 et le 11 mai 2022. Compte tenu du manque de données probantes directes concernant les effets de la corticothérapie prénatale en période de prématurité tardive sur le devenir neurodéveloppemental, les auteurs ont résumé les données concernant les effets de la corticothérapie prénatale sur le devenir neurodéveloppemental dans tous les âges gestationnels en utilisant les sources suivantes : (1) l'analyse Cochrane de 2020 et (2) les données probantes obtenues à partir de recherches dans les bases de données Ovid MEDLINE, Embase et Cochrane Central Register of Controlled Trials (CENTRAL) de leur création au 15 janvier 2022. Aucune restriction n'a été appliquée en ce qui concerne la date ou la langue de publication. Compte tenu du manque de données probantes directes concernant les effets de la corticothérapie prénatale en cas de prématuré sur les issues à long terme, les auteurs ont résumé les données concernant les effets de la corticothérapie prénatale sur les autres issues à long terme dans tous les âges gestationnels en combinant les données de l'analyse Cochrane de 2020 et celles tirées des études observationnelles abordant les effets à long terme de la corticothérapie prénatale sur la croissance, le devenir cardiométabolique et le devenir respiratoire, études répertoriées dans Ovid MEDLINE et publiées de sa création au 22 octobre 2021. Les auteurs ont examiné la bibliographie des études et revues systématiques retenues afin d'obtenir des références supplémentaires. Voir l'annexe A pour connaître les termes de recherche et consulter les résumés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe B en ligne (tableau B1 pour les définitions et tableau B2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Fournisseurs de soins de maternité, notamment les sages-femmes, les médecins de famille et les obstétriciens.

There are multiple conventions for gestational age notation, which lead to different interpretations of completed weeks. This variability is exemplified by the different gestational age ranges recommended for administration of antenatal corticosteroid prophylaxis. Antenatal corticosteroid prophylaxis is widely recommended for women at risk of preterm delivery up to 34 completed weeks gestation. According to the World Health Organization, 34 completed weeks refers to the time period from the first day of the last menstrual period (day zero) to 34 weeks and 6 days of gestation (i.e., to 34+6 34 weeks, or 244 days gestation). However, an alternative convention interprets 34 completed weeks as the period from the first day of the last menstrual period to 33+6 36 weeks' gestation (i.e., 237 days' gestation). These inconsistencies in gestational age notation may have led to different practice recommendations for antenatal corticosteroid prophylaxis worldwide. Agreeing on the World Health Organization notation and interpretation of completed weeks may help promote clear communication within our discipline and more precise and effective knowledge dissemination.

Objectives: To compare the demographic and clinical characteristics between women who chose elective repeat Caesarean section (ERCS) versus trial of labour after Caesarean section (TOLAC) in St. John's, Newfoundland and Labrador (NL). Methods: We conducted a retrospective case control study of women with live singleton gestations delivering at term in St. John's, NL between January 1, 2001 and December 31, 2014. Inclusion criteria were women who had a previous single lower segment Caesarean section (LSCS). TOLAC, successful TOLAC, and VBAC rates were calculated. Demographic and clinical characteristics were compared between women who chose ERCS versus TOLAC. Univariate analyses and multiple logistic regression analyses were performed, and adjusted odds ratios (aOR) and 95% CIs were calculated. Results: A total of 1579 women were included, of whom 160 (10.1%) chose TOLAC, with 107 resulting in successful VBAC (67% successful TOLAC rate). The overall VBAC rate was 6.8%. Women who chose ERCS compared with those who chose TOLAC were more likely to be obese (aOR 3.20, 95% CI 1.85-5.54, P < 0.001), less likely to have had GA at delivery greater than 40 weeks (aOR 0.13, 95% CI 0.08-0.21, P < 0.001), less likely to have had a previous vaginal delivery (aOR 0.40, 95% CI 0.20-0.80, P < 0.001), and less likely to have had the previous CS for breech presentation (aOR 0.51, 95% CI 0.33-0.80, P = 0.003). Conclusions: The overall TOLAC and VBAC rates in St. John's are low when compared with reported national rates. The successful TOLAC rate is within the expected range reported in the literature. Differences exist between women who chose ERCS compared with TOLAC.

Purpose: To compare breastfeeding initiation rates for women across body mass index (BMI) classes, including normal BMI (18.50 − 24.99 kg/m²), overweight (25.00 − 29.99 kg/m²), obese (30.00 − 39.99 kg/m²), morbidly obese (40.00 − 49.99 kg/m²) and extreme obesity (> 50.00 kg/m²). Materials and methods: Retrospective cohort of women with singleton pregnancies, delivering in St. John’s, NL between 2002–2011. The primary outcome was any breastfeeding on hospital discharge. Breastfeeding rates across BMI categories were compared, using univariate analyses. Multivariate analysis included additional maternal and obstetric variables. Results: Twelve thousand four hundred twenty-two women were included: 8430 breastfed and 3992 did not breastfeed on hospital discharge. Progressively decreasing rates of breastfeeding were noted with increasing obesity class: normal BMI (71.1%), overweight (69.1%), obese (61.6%), morbidly obese (54.2%) and extremely obese women (42.3%). Multivariate analysis confirmed that increasing obesity class resulted in lower odds of breastfeeding: overweight (adjusted odds ratios (aOR) 0.86,95%CI 0.76–0.98), obese (aOR 0.65,95%CI 0.57–0.74), morbidly obese (aOR 0.57,95%CI 0.44–0.74) and extreme obesity (aOR 0.37,95%CI 0.19–0.74). Conclusion: Women in higher obesity classes are progressively less likely to initiate breastfeeding. Women with the highest prepregnancy BMIs should be particularly counseled on the benefits of breastfeeding.

Objective: Atonic postpartum hemorrhage rates have increased in many industrialized countries in recent years. We examined the blood loss, risk factors, and management of the third stage of labour associated with atonic postpartum hemorrhage. Methods: We carried out a case-control study of patients in eight tertiary care hospitals in Canada between January 2011 and December 2013. Cases were defined as women with a diagnosis of atonic postpartum hemorrhage, and controls (without postpartum hemorrhage) were matched with cases by hospital and date of delivery. Estimated blood loss, risk factors, and management of the third stage labour were compared between cases and controls. Conditional logistic regression was used to adjust for confounding. Results: The study included 383 cases and 383 controls. Cases had significantly higher mean estimated blood loss than controls. However, 16.7% of cases who delivered vaginally and 34.1% of cases who delivered by Caesarean section (CS) had a blood loss of < 500 mL and < 1000 mL, respectively; 8.2% of controls who delivered vaginally and 6.7% of controls who delivered by CS had blood loss consistent with a diagnosis of postpartum hemorrhage. Factors associated with atonic postpartum hemorrhage included known protective factors (e.g., delivery by CS) and risk factors (e.g., nulliparity, vaginal birth after CS). Uterotonic use was more common in cases than in controls (97.6% vs. 92.9%, P < 0.001). Delayed cord clamping was only used among those who delivered vaginally (7.7% cases vs. 14.6% controls, P = 0.06). Conclusion: There is substantial misclassification in the diagnosis of atonic postpartum hemorrhage, and this could potentially explain the observed temporal increase in postpartum hemorrhage rates.

Objective To compare the rate of any breastfeeding at the time of postpartum hospital discharge between obese women (BMI ≥ 30.00 kg/m²) and women with a normal BMI (18.50 to 24.99 kg/m²). Methods We conducted a retrospective cohort study of women with live, singleton pregnancies who delivered in St. John's, Newfoundland and Labrador between 2002 and 2011, using data from the Newfoundland and Labrador provincial perinatal registry. The primary outcome was any breastfeeding at the time of discharge from hospital. Secondary analysis included comparison of breastfeeding rates by class of obesity. We compared additional maternal and neonatal outcomes between women who were breastfeeding at discharge and those who were not. Univariate and multivariate logistic regression analyses were performed, and adjusted odds ratios (aORs) and 95% CIs were calculated. Results We included 12 831 women with BMI data available in the study: 8676 were breastfeeding and 4155 were not at the time of postpartum discharge. Obese women were less likely to breastfeed than women with normal weight (60.0% vs. 71.7%) (aOR 0.63; 95% CI 0.55 to 0.71). Multivariate analysis showed a significant effect on the primary outcome of a mother's age (aOR 1.03; 95% CI 1.02 to 1.05), nulliparity (aOR 1.73; 95% CI 1.51 to 1.98), being partnered (aOR 1.57; 95% CI 1.34 to 1.84), working (aOR 1.10; 95% CI 1.02 to 1.19), having higher education (aOR 1.48; 95% CI 1.38 to 1.60), smoking (aOR 0.35; 95% CI 0.29 to 0.43), having gestational diabetes (aOR 0.70; 95% CI 0.5 to 0.92), pre-existing hypertension (aOR 0.58; 95% CI 0.39 to 0.87), gestational hypertension (aOR 0.67; 95% CI 0.55 to 0.82), and undergoing general anaesthesia (aOR 0.41; 95% CI 0.22 to 0.77). Conclusion Obesity is an independent risk factor for not breastfeeding at the time of postpartum discharge from hospital. It is important to counsel women on the benefits of breastfeeding, emphasizing these particularly in women with a high pre-pregnancy BMI.

Objective: To estimate whether cervical length measured by transvaginal ultrasonography in women with a history of hysteroscopic uterine septum resection predicts spontaneous preterm birth <35 weeks' gestation. Methods: This retrospective cohort study compared women who had undergone hysteroscopic metroplasty, and were subsequently pregnant with singleton gestations delivered January 2003 to December 2012, to a low-risk control group. Transvaginal ultrasonographic cervical lengths were measured 16-30 weeks' gestation. The primary outcome was spontaneous preterm birth <35 weeks' gestation and the primary exposure variable of interest was cervical length. Results: Women with a uterine septum resected (N = 24) had a shorter cervical length (2.90 cm) than the low-risk control group (N = 141, 4.31 cm, p < 0.0001); and were more likely to have a cervical length <3.0 cm (41.7% versus 1.4%, p < 0.0001), <2.5 cm (33.3% versus 0%, p < 0.0001), <2.0 cm (16.7% versus 0%, p < 0.0001) and <1.5 cm (12.5% versus 0%, p = 0.003). Women with septum resected were more likely to receive corticosteroids (33.3% versus 11.3%, p = 0.010), but were not more likely to have a spontaneous preterm birth <35 weeks (4.2% versus 0.7%, p = 0.27). There were no differences noted in secondary outcomes including neonatal morbidity. Conclusion: Pregnant women with a history of a hysteroscopic uterine septum resection have shorter cervical lengths than low-risk controls but may not be at a higher risk of spontaneous preterm birth <35 weeks' gestation. Further research with a larger sample size is needed to evaluate this group of women to determine if transvaginal ultrasonographic cervical length assessment is of benefit.

Objective: To evaluate the effects of extreme obesity (pre-pregnancy BMI ≥ 50.0 kg/m2) in pregnancy on maternal and perinatal outcomes. Methods: We conducted a population-based cohort study using the Newfoundland and Labrador Perinatal Database to compare obstetric outcomes in women with extreme obesity and those with a normal BMI (pre-pregnancy BMI 18.50 to 24.99 kg/m2). We included women with singleton gestations who gave birth between January 1, 2002, and December 31, 2011. Maternal outcomes of interest included gestational hypertension, gestational diabetes, Caesarean section, shoulder dystocia, length of hospital stay, maternal ICU admission, postpartum hemorrhage, and death. Perinatal outcomes included birth weight, preterm birth, Apgar score, neonatal metabolic abnormality, NICU admission, stillbirth, and neonatal death. A composite morbidity outcome was developed including at least one of Caesarean section, gestational hypertension, birth weight ≥ 4000 g, birth weight < 2500 g, or NICU admission. Univariate analyses and multivariate logistic regression analyses (controlling for maternal age, parity, smoking, partner status, and gestational age) were performed, and adjusted odds ratios (aORs) and 95% confidence intervals were calculated. Results: A total of 5788 women were included in the study: 71 with extreme obesity and 5717 with a normal BMI. Extremely obese women were more likely to have gestational hypertension (19.7% vs. 4.8%) (aOR 1.56; 95% CI 1.33 to 1.82), gestational diabetes (21.1% vs. 1.5%) (aOR 2.04; 95% CI 1.74 to 2.38), shoulder dystocia (7.1% vs. 1.4%) (aOR 1.51; 95% CI 1.05 to 2.19), Caesarean section (60.6% vs. 25.0%) (aOR 1.46; 95% CI 1.29 to 1.65), length of hospital stay more than five days (excluding Caesarean section) (14.3% vs. 4.7%) (aOR 1.42; 95% CI 1.07 to 1.89), birth weight ≥ 4000 g (38.0% vs. 11.9%) (aOR 1.58; 95% CI 1.38 to 1.80), birth weight ≥ 4500 g (16.9% vs. 2.1%) (aOR 1.87; 95% CI 1.57 to 2.23), neonatal metabolic abnormality (8.5% vs. 2.0%) (aOR 1.50; 95% CI 1.20 to 1.86), NICU admission (16.9% vs. 7.8%) (aOR 1.28; 95% CI 1.07 to 1.52), stillbirth (1.4% vs. 0.2%) (aOR 1.68; 95% CI 1.00 to 2.82) and composite adverse outcome (81.7% vs. 41.5%) (aOR 1.57; 95% CI 1.35 to 1.83). Conclusion: Women with extreme obesity have increased risks of a variety of adverse maternal and perinatal outcomes. As approximately 6 per 1000 women giving birth in our population have extreme obesity, it is important to address these risks pre-conceptually and encourage a healthier BMI before pregnancy.