The history of the emergence of forceps as an effective delivery intervention was cloaked in secrecy for over 100 years by the Chamberlen family, until 5 pairs of the instruments were discovered under the floorboards of Woodham Mortimer Hall in England in 1813. For several prior generations of their family's practice, these secretive instruments were used in an attempt to save one or both lives. Fast forward through the invention of chloroform analgesia by Sir James Young Simpson in Edinburgh in the 1870s, via the refinement of forceps to include rotational delivery by the Norwegian Christian Kielland in 1915, the establishment of modern sterility techniques in the 1950s, and the advent of safe epidural analgesia in the 1970s, one might expect the use of these instruments to be well-defined in 2024.

L'histoire des forceps comme instrument efficace pour l'accouchement assisté a été tenue secrète pendant plus de 100 ans par la famille Chamberlen jusqu'à ce que 5 paires de forceps soient découvertes en Angleterre en 1813, sous le plancher de Woodham Mortimer Hall. Pendant plusieurs générations, ces instruments ont été utilisés clandestinement dans leur pratique familiale pour tenter de sauver une ou deux vies. Après l'invention de l'analgésie au chloroforme par sir James Young Simpson à Édimbourg dans les années 1870, le perfectionnement de la rotation aux forceps à l'accouchement par le Norvégien Christian Kielland en 1915, l'adoption des techniques modernes de stérilisation dans les années 1950 et l'avènement de l'analgésie péridurale sûre dans les années 1970, on pourrait s'attendre à ce que l'utilisation de ces instruments soit bien définie en 2024.

OBJECTIVE:Women with germline BRCA1/2 pathogenic variants have a significantly elevated lifetime risk of ovarian and fallopian tube cancer. Bilateral salpingo-oophorectomy (RRSO) is associated with a 90% reduction in the development of tubal and ovarian cancer. At our tertiary hospital, we have a dedicated clinic where women predisposed to hereditary ovarian/tubal cancer receive counseling on reproduction, risk reduction, surgical prophylaxis, and menopausal aftercare. The objective of this study was to evaluate the choices that Canadian women with BRCA1/2 pathogenic variants make regarding ovarian cancer risk reduction within this highly specialized multidisciplinary clinic.METHODS:This retrospective chart review included all women with confirmed BRCA1/2 mutations referred to the Familial Ovarian Cancer Clinic at Women's College Hospital, Toronto, Canada over a 45-month time period. Patient demographics, preoperative consultation notes and investigations, intraoperative findings, and pathology were recorded.RESULTS:A total of 191 women were included in our cohort; 140 (73.3%) underwent risk-reducing surgery and 51 (26.7%) deferred or declined surgery. In women who underwent surgical prevention (median age 45 [30-72] y), 123 (87.9%) underwent RRSO and 17 (12.1%) chose a risk-reducing bilateral salpingectomy with deferred oophorectomy. Of the women undergoing RRSO, 11 (8.9%) women chose concurrent hysterectomy. Prevalent themes affecting decision-making included fears around premature surgical menopause, family planning, and concerns around development of endometrial cancer related to tamoxifen.CONCLUSION:Women with BRCA1/2 pathogenic variants face challenging decisions regarding risk reduction and care providers must be knowledgeable and supportive in helping women make informed and individualized choices about their care.

Patients presenting with a positive pregnancy test and vaginal bleeding or pelvic pain routinely undergo transvaginal ultrasound as the standard diagnostic assessment. Pregnancy of unknown location is a classification that describes patients with a positive beta-human chorionic gonadotropin (β-hCG

The term preeclampsia describes a syndrome comprising a group of new-onset hypertensive complications of pregnancy that have the potential to inflict serious harm on the mother and her developing fetus. The traditional definition combined hypertension with proteinuria, implying renal injury, but has recently been expanded to include a wider range of maternal end-organ dysfunction and the fetal manifestations of placental dysfunction; as such, the definition no longer requires the presence of proteinuria. 1 ACOG Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013; 122: 1122-1131 Crossref PubMed Scopus (795) Google Scholar The most severe forms of preeclampsia are associated with placental disease. Over the past decade, much has been learned regarding the pathophysiologic link between the abnormal placenta and the initiation of multiorgan maternal morbidity that manifests in women with severe preeclampsia. This body of knowledge has now focused on one circulating growth factor arising from the placenta: placental growth factor, whose measurement has the potential to alter clinical practice to substantially reduce the burden of this disease on pregnant women and their developing offspring.

Objective To develop an integrated checklist for the management of patients with suspected morbidly adherent placenta (MAP). Methods A checklist process was developed incrementally by clinicians in the disciplines of maternal-fetal medicine, gynaecology, medical imaging, and anaesthesia for management of women with suspected MAP. Results Over a five-year period of debriefing after individual cases, a comprehensive checklist system was developed. The checklist is activated upon referral if MAP is suspected at an initial maternal-fetal medicine consultation; the process is subsequently guided by a clinical nurse specialist, leading to a standardized program of care. Conclusions Having a checklist process facilitates standardized care and optimal communication between specialists, providing team-based care for women with this potentially serious complication of pregnancy.

OBJECTIVE:The objective of this study was to determine whether a web-based education strategy could improve maternal knowledge of placental complications of pregnancy and reduce maternal anxiety in high risk-pregnancies.METHODS:Prospective study in the Placenta Clinic at Mount Sinai Hospital, Toronto, Ontario. Maternal demographics and Internet usage were recorded at the patient's baseline appointment. Placental knowledge was determined using structured verbal and illustrative assessments. The six-item State-Trait Anxiety Inventory (STAI) was administered to assess baseline maternal anxiety. Women were asked to visit the Placenta Clinic website for a minimum of 15 minutes before their follow-up appointment, at which time their placental knowledge and STAI assessments were repeated.RESULTS:Eighteen women were included in the study. Patient knowledge at the baseline appointment was generally poor (median score 10.5 out of a maximum score of 27, range 1 to 22), with major deficits in basic placental knowledge, placenta previa/increta, and preeclampsia. At the follow-up appointment, placental knowledge was significantly improved (median score 23, range 10 to 27; P < 0.001). Educational status (high school or less vs. college or more) had no effect on either baseline knowledge or knowledge improvement. Maternal anxiety at baseline (median score 12 out of a maximum score of 24, range 6 to 23) was significantly reduced at the follow-up appointment (median score 8.5, range 6 to 20; P = 0.005).CONCLUSION:Deficits in maternal knowledge of placental complications of pregnancy in high-risk pregnant women were substantial but easily rectified with a disease-targeted web-based educational resource. This intervention significantly improved patient knowledge and significantly reduced maternal anxiety.

Objective: To assess the effectiveness of a multidisciplinary team approach to reduce severe maternal morbidity in women with invasive placenta previa.Methods: We conducted a prospective study of 33 women with placenta previa and increta-percreta (diagnosed by ultrasound and/or magnetic resonance imaging) delivering at Mount Sinai Hospital, Toronto, following the introduction in January 2008 of a team-based approach to women with this condition. We included women who delivered by June 2012. We reviewed antenatal outpatient and inpatient records for use of six pre-defined team components by the attending staff obstetrician: (1) antenatal maternal-fetal medicine consultation, (2) surgical gynaecology consultation, (3) antenatal MRI, (4) interventional radiology consultation and preoperative placement of balloon catheters in the anterior divisions of the internal iliac arteries, (5) pre-planned surgical date, and (6) surgery performed by members of the invasive placenta surgical team. Antenatal course, delivery, and postpartum details were recorded to derive a five-point composite severe maternal morbidity score based on the presence or absence of: (1) ICU admission following delivery, (2) transfusion > 2 units of blood, (3) general anaesthesia start or conversion, (4) operating time in highest quartile (> 125 minutes), and (5) significant postoperative complications (readmission, prolonged postpartum stay, and/or pulmonary embolism).Results: All 33 women survived during this time period. Two thirds (22/33) had either five or six of the six components of multidisciplinary care. Increasing use of multidisciplinary team components was associated with a significant reduction in composite morbidity (R-2 = 0.228, P = 0.005).Conclusion: Team-based assessment and management of women with invasive placenta previa is likely to improve maternal outcomes and should be encouraged on a regional basis.

Uterine artery Doppler ultrasound assessment is used to assess uteroplacental blood flow and the risk of placental ischemic-thrombotic injury in high-risk pregnancies. We report here a case in which this examination identified the presence of a maternal atrial arrhythmia.A 50-year-old woman with no significant past medical history received antenatal care in our fetal medicine unit clinic because of advanced maternal age, a history of recurrent pregnancy loss, multiple uterine fibroids, and a history of in vitro fertilization using donated oocytes. Uterine artery Doppler ultrasound was normal at 19 weeks, but was repeated at 33 weeks because of abnormal placental texture and maternal risks, revealing an irregular maternal heart rhythm. Paroxysmal atrial fibrillation was confirmed by Holter monitor at 34 weeks. The patient was asymptomatic and declined the cardiologist's recommendation of antepartum and postpartum anticoagulation. She remained asymptomatic and had delivery by Caesarean section at term.Uterine artery Doppler flow studies may identify a significant maternal cardiac arrhythmia.

Objective: To determine whether the predominant phenotype of intrauterine growth restriction (IUGR) is symmetric or asymmetric in severe, early-onset disease due to placental insufficiency.Methods: We conducted a retrospective chart review of high-risk pregnant women with severe, early-onset IUGR who were delivering at < 33+0 weeks' gestation at Mount Sinai Hospital from 2001 to 2010. Ultrasound images were reviewed for fetal biometry, amniotic fluid volume, and uterine and umbilical Doppler flow studies within seven days of delivery, and the frequency of head circumference/abdominal circumference ratio >= 95th percentile for gestation was determined.Results: Sixty-two of 107 pregnancies (58%) with early-onset IUGR had an elevated HC/AC ratio (>= 95th percentile), which was more than 10-fold greater than the expected proportion (P < 0.001). High rates of severe preeclampsia (53%), abnormal amniotic fluid (70%), and abnormal uterine artery Doppler studies (78%) indicated placental insufficiency.Conclusion: Fetuses with severe placental IUGR in the second trimester are more likely to have an asymmetric phenotype. This is in contrast to the current belief that asymmetric IUGR is confined to third trimester IUGR.

OBJECTIVE:Advanced placental maturation (Grannum [G] grade 3) before term is associated with adverse perinatal outcomes associated with placental insufficiency. The nature and timing of the underlying pathology of this process is presently unclear. We hypothesized that advanced placental maturation at 30 to 34 weeks' gestation is not associated with established second trimester markers of severe placental dysfunction.METHODS:In a cohort study of 1238 low-risk Caucasian women with singleton pregnancies who had sonographic assessment of placental maturation and fetal growth at 34 weeks, the results of maternal serum screening (MSS) and uterine artery Doppler (UtAD) flow studies at 16 weeks were related to adverse perinatal outcomes associated with placental insufficiency: antepartum hemorrhage, preeclampsia, preterm birth < 37 weeks, small for gestational age (< 10th percentile), or postnatal evidence of intrauterine growth restriction (IUGR; ponderal index < 5th percentile).RESULTS:G1 was found in 127 women (10.3%), G2 was found in 18 women (1.5%), and no cases of G3 were observed. Advanced Grannum grading was significantly associated with IUGR (48 [4.4%] in G0, 9 [7.1%] in G1, 5 [27.8%] in G2; P < 0.001), but was dependent on smoking status. IUGR was not predicted by abnormal MSS or abnormal UtAD findings at either the second or third trimester ultrasounds.CONCLUSION:G2 maturation at 30 to 34 weeks' gestation is associated with mild IUGR at delivery in low-risk women and with smoking. IUGR was not predicted by either second or third trimester markers of severe placental dysfunction. Future studies directly observing the placenta in the late third trimester may aid the elusive diagnosis of "late-onset" mild IUGR.