OBJECTIVE:To assess whether deferred cord clamping (DCC) is associated with reduced death and/or severe brain injury compared to early cord clamping (ECC) in very and extremely preterm monochorionic-diamniotic (MCDA) twins. STUDY DESIGN:This multicenter retrospective cohort study included liveborn MCDA twins born under 32 weeks of gestation and admitted to any tertiary-level neonatal intensive care unit (NICU) participating in the Canadian Neonatal Network (CNN) in Canada between 2018 and 2023. We compared DCC ≥30s to ECC<30s. The primary composite outcome was death before discharge and/or severe brain injury (intraventricular hemorrhage ≥ grade III and/or cystic periventricular leukomalacia). Secondary outcomes included neonatal morbidities and interventions. Adjusted odds ratios (aORs) for categorical variables and ratio of means for continuous variables were estimated with 95% confidence intervals (CIs). Generalized estimating equation (GEE) models accounted for the correlation between twins. RESULTS:Approximately 42% of first-born and 54% of second-born MCDA twins received DCC. The primary composite outcome of death and/or severe brain injury occurred in 10% (48/488) of twins who received DCC and 16% (82/529) of those who received ECC (aOR 0.93; 95% CI 0.60-1.45). Among secondary outcomes, there were no significant differences in neonatal morbidities or interventions, except for a significant reduction in red blood cell transfusions, with 24% (115/488) of twins in the DCC group receiving at least one transfusion versus 43% (229/529) in the ECC group (aOR 0.46; 95% CI 0.33-0.66). CONCLUSIONS:Among MCDA twins born at < 32 gestational weeks, DCC did not impact the risk of death and/or severe brain injury compared to ECC but it was associated with decreased need for transfusions.

The rate of multiple births has surged. Twins, especially those with monochorionic placentation, face a higher risk of neonatal mortality, morbidity and very preterm birth compared to singletons. Deferred cord clamping (DCC) is the standard for preterm singletons. While DCC is known to reduce the risk of mortality and morbidity in preterm singletons, its efficacy and safety in very preterm twins, especially monochorionic twins, remain scarcely explored. This study aimed to assess whether DCC, compared with early cord clamping (ECC), was associated with a reduction in death and/or severe brain injury in very and extremely preterm monochorionic-diamniotic twins. This multicenter retrospective cohort study included liveborn monochorionic-diamniotic twins of <32 gestational weeks admitted to a tertiary-level neonatal intensive care unit (NICU) in Canada between 2018 and 2023 using the Canadian Neonatal/Preterm Birth Network (CNN/CPTBN) database. We compared DCC ≥30s and ECC <30s. The primary outcome was a composite of death before discharge and/or severe brain injury. Secondary outcomes included neonatal morbidity and clinical outcomes. We calculated crude odds ratios (ORs) and adjusted ORs for categorical variables and ratio of means for continuous variables, along with 95% confidence intervals (CI). Models were fitted with generalized estimated equations accounting for twin correlation. 1017 neonates were included (DCC 488 [48.0%]; ECC 529 [52.0%]). Death and/or severe brain injury occurred in 10% (n=48) of twins who received DCC and in 16% (n=82) of those who received ECC. There was no significant difference between the groups (aOR 0.93; 95% CI 0.60-1.45). There was a significant reduction in red blood cell transfusions (aOR 0.46; 95% CI 0.33-0.66). Among monochorionic-diamniotic twins born before 32 weeks of gestation, DCC did not impact the incidence of death and/or severe brain injury compared to ECC but was associated with decreased need for transfusions.

Abstract Introduction: The main objective of this study was to explore how the Quebec Perinatal Policy influenced the collaborative experiences of maternity care providers in a birthing center and its affiliated hospital. Methods: A single case study was used. Data collection included semi-structural interviews with multidisciplinary professional and administrator participants; direct observation and field notes; documents and archives. A qualitative thematic method and QDA Miner software were used for analysis. Results: Our investigation reveals that midwives have complete access to the hospital with which a formal agreement was signed. The completion of the Quebec Perinatal Policy is still under question because of the lack of human and financial resources. Some of the barriers to fully execution of the Perinatal Policy in the province of Quebec include the absence of strategies or willingness to open more birthing centers, the scarcity of training sites for midwives, and the limited number of schools that provide midwifery education in Quebec. There was no obvious effect of Quebec Perinatal Policy on the collaborative professional activities among midwives in the birthing center and other professionals in the affiliated hospital. Tension among maternity care professionals was fuelled by prejudice, a poor understanding of the roles and lack of trust of other professionals, poor communication, and an unwillingness to collaborate. Factors that facilitated collaboration between maternity care professionals were close communication and exchange of information between personnel, participation in multidisciplinary workshops and meetings, and proper preparation of midwifery clients for possible transfer of care. Conclusion: Collaboration is necessary among maternity care professionals in order to better implement the perinatal care policies in Quebec. Additional strategies include clearly defining the roles and responsibilities of the various maternity care providers, designing interdisciplinary programs and workshops to strengthen teamwork and to improve understanding of the scope of practice of other maternity care professionals, in order to encourage mutual respect and collaboration.

INTRODUCTION: First-trimester bleeding is associated with miscarriage and preterm birth, for which progesterone has been suggested to improve outcomes. Our study objective was to evaluate the effect of progesterone treatment throughout pregnancy on preventing miscarriage and preterm birth in pregnancies with first trimester bleeding. METHODS: This was a multicenter, double-blind, placebo-controlled, randomized trial comparing 200 mg micronized progesterone, vaginally administered nightly from presentation to 34 weeks of gestation, with an identically appearing placebo. Subjects with vaginal bleeding and live intrauterine pregnancy <14 weeks of gestation were eligible. Multifetal gestations, cervical insufficiency, recurrent pregnancy loss, or bleeding unrelated to placentation were excluded. Primary outcome was occurrence of live term pregnancy. Secondary outcomes included adverse maternal/newborn events and time to miscarriage or birth. Chi-square analyses compared proportions and Mann-Whitney tests compared time-to-event outcomes. RESULTS: A total of 549 patients were randomized, of whom 16 withdrew or were lost to follow-up, leaving 264 patients in the progesterone group and 269 patients in the placebo group. Baseline characteristics were comparable in both groups. The number of patients having a live term birth among those in the progesterone group was 197 (74.6%), compared with 190 (70.6%) in the placebo group (P=.30). Compared to the placebo group, those in the progesterone group had comparable risks of abortion <20 weeks (38 (14.4%) versus 43 (16.0%), P=.94), preterm birth (27 [10.2%] versus 33 [12.3%], P=.46), and stillbirth (2 [0.9%] versus 3 [1.3%], P=.65). There were no differences in adverse maternal or newborn outcomes, or in time-to-event for miscarriage or birth between the groups. CONCLUSION: Progesterone prescribed throughout pregnancy is not effective in preventing miscarriage or prematurity in subjects presenting with first-trimester vaginal bleeding in context of a live intrauterine pregnancy.

Background The hemodynamic and physiological changes of pregnancy may predispose women to cardiac arrhythmias such as atrial fibrillation (AF). Nevertheless, new-onset AF in pregnancy remains rare, and treatment is challenging. Current recommendations are to treat pregnant women with AF as non-pregnant adults, by using pharmacological or synchronized electrical cardioversion, without mention of gestational age or possibility of delivery. Case A 23-year-old nulliparous woman developed new-onset symptomatic AF at 362 weeks gestation, but presented to our hospital was delivered at 364 weeks gestation. Beta-blockers were administered for heart rate control. After 48 hours, the decision was made to proceed with delivery rather than cardioversion. The patient's arrhythmia resolved spontaneously postpartum without further treatment. Conclusion In pregnant patients near or at term, delivery should be considered in the management of new-onset AF after consultation with cardiology, anaesthesiology, and maternal-fetal medicine.

Objective: Early subchorionic hemorrhage may lead to a disruption in the placental-uterine matrix, which may result in an adherence of the placenta to the endometrium. We evaluated the effect of a first-trimester bleed on the need for a post-vaginal delivery dilatation and curettage (D&C) for removal of retained placenta. Methods: We conducted a case-control study at a tertiary care centre between 2012 and 2016. Patients identified through medical records as having required a post-vaginal delivery D&C for retained placenta were considered cases and were matched 1:5 with patients delivering vaginally within 1 week who did not require a D&C. History of first-trimester bleeding and subchorionic hemorrhage were identified through chart review. Conditional logistic regression analyses estimated the effect of a first-trimester bleed on the requirement for D&C for retained placenta. Models were adjusted for maternal age and previous uterine surgery. Results: There were 68 cases of retained placenta requiring D&C, for an estimated 3 in 1000 deliveries. Patients requiring D&C were slightly older than controls but were otherwise comparable with respect to baseline demographic characteristics. In adjusted analyses, patients who required a postpartum D&C were more likely than controls to have had a first-trimester bleed at 11.8% and 0.6%, respectively (OR 25.3; 95% CI 4.7-135.4, P < 0.001). Postpartum D&C for retained placenta was associated with postpartum hemorrhage, need for blood transfusion, and manual removal of placenta. Conclusion: First-trimester bleeding should be considered a high-risk determinant for post-vaginal delivery D&C for retained placenta and for severe postpartum hemorrhage.

BACKGROUND:A better understanding of the processes of collaboration between midwives who work in the birthing centers, and hospital-based obstetricians, family physicians and nurses may promote cooperation among professionals providing maternity care in both institutions. The aim of this research was to explore the barriers and facilitators of the interprofessional and interorganizational collaboration between midwives in birthing centers and other health care professionals in hospitals in Quebec.METHODS:A case study design was adopted. Data were collected through semi-structured interviews with midwives, multidisciplinary professionals and administrators, through direct observation of activities in maternity units and field notes, and a variety of organizational and policy documents and archives. A qualitative thematic analysis method was used for analyzing transcribed verbatim.RESULTS:The study suggests the close intertwinement between interactional, organizational and systemic factors in regard to barriers and opportunities for collaboration between midwives in birthing centers, and physicians and nurses in hospitals in Quebec. At interactional level, our findings show a conflict in scope of midwifery practice, myth about midwives, pre-judgment, and lack of communication skills between health care providers in the studied birthing center and hospital. At the organizational level, this investigation shows that although midwives have complete access to the hospital with which a formal agreement was signed, they were not integrated in hospital because of lack of interest of midwives and differences in philosophy and scope of practice among healthcare professionals as well as the culture of organizations. At a systemic level, in spite of excessive demand for midwifery care, there are not enough midwives to cover these demands.CONCLUSION:Maternity care professionals require taking a collaborative approach in working and the boundaries of responsibility need to be redrawn. The inter-professional collaborative work between midwives and other maternity care professionals is crucial to improve access and women's choices for maternity care in Canada. Although having collaborative and multidisciplinary teamwork is a goal of maternity care systems, it is hard to achieve.

Objectives-Medical management is commonly used among women with early pregnancy failure. The purpose of our study was to evaluate uterine content sonographic measurements for predicting medical management failure in early pregnancy loss.Methods-We conducted a retrospective cohort study in a university-affiliated hospital center including all women discharged from the emergency department (ED) with a diagnosis of early pregnancy failure who had medical management with misoprostol between 2011 and 2013. Only women with sonograms available for review were included in our study. All images were reviewed and the following cavity measurements, excluding the endometrial lining, were measured: cavity anteroposterior distance, cavity longitudinal distance, cavity transverse distance, and cavity volume. Logistic regression analysis was used to identify measurements that were independently associated with a subsequent need for dilation and curettage (D&C) and an unplanned return to the ED.Results-Among 823 women presenting to the ED with first-trimester bleeding, 227 met inclusion criteria. Of all measurements evaluated, the cavity anteroposterior distance was found to be independently associated with D&C and an unplanned return to the ED. When a cavity anteroposterior distance cutoff of 15 mm was used, women were more likely to require D&C (adjusted odds ratio, 2.65; 95% confidence interval, 1.31-5.36; P<.01) and to have an unplanned return to the ED (adjusted odds ratio, 2.59; 95% confidence interval, 1.41-4.79; P <.01). In women with a cavity anteroposterior distance of less than 15 mm, 87.1% had successful medical management of early pregnancy loss, and 80.0% did not require an unplanned return to the ED.Conclusions-Although there is a need for further validation, patients identified as having a cavity anteroposterior distance of less than 15 mm should be considered good candidates for successful medical management.

Primary fallopian tube cancer in pregnancy is rare and is even more so for the clear cell variant. Our case is the third case of primary fallopian tube cancer in pregnancy and the first case of clear cell adenocarcinoma of the fallopian tube in pregnancy. The patient presented with increasing pelvic pain starting in the second trimester. Serial ultrasound evaluations were performed and revealed a rapidly growing complex adnexal mass adjacent to the uterus. Her pregnancy was further complicated by spontaneous preterm labor and she delivered prematurely per vaginam at 31 weeks. She underwent an urgent laparotomy in the immediate postpartum period for acute aggravation of her right pelvic pain and fever. The diagnosis of tubal clear cell adenocarcinoma was subsequently made on histopathology examination.

Objective We estimated the extent to which Canadian expectant parents would seek medical care in a febrile neonate (age 30 days or less). We also evaluated expectant parents’ knowledge of signs and symptoms of fever in a neonate, and explored the actions Canadian expectant parents would take to optimize the health of their child. Methods We conducted a cross-sectional survey of a sample of expectant parents from a large urban center in Canada. We recruited participants from waiting rooms in an obstetrical ultrasound clinic located in an urban tertiary care hospital in Montreal, Canada. We asked participants nine questions about fever in neonates including if, and how, they would seek care for their neonate if they suspected he/she were febrile. Results Among the 355 respondents, (response rate 87%) we found that 75% of parents reported that they would take their febrile neonate for immediate medical assessment, with nearly one fifth of the sample reporting that they would not seek medical care. We found no significant associations between the choice to seek medical care and expectant parents socio-demographic characteristics. Conclusions Despite universal access to high quality health care in Canada, our study highlights concerning gaps in the knowledge of the care of the febrile infant in one fifth of expectant parents. Physicians and health providers should strive to provide early education to expectant parents about how to recognize signs of fever in the neonate and how best to seek medical care. This may improve neonatal health outcomes in Canada.

To assess the impact of changes in systemic venous returns (decreased inferior vena cava and relative increase in superior vena cava flows) on respective ventricular performances and O2 transport to the brain. In this prospective multicenter study, the aortic Isthmic Systolic Index (ISI = systolic nadir divided by the peak velocity of the waveform) and the Isthmic Time Systolic Index (ITSI = duration of systolic reverse flow divided by the total time of systolic ejection) were measured weekly in a cohort of growth restricted fetuses and compared to a population of normals. Pulsatility indices of the umbilical (UPI) and middle cerebral arteries (MCAPI) were also calculated. Data were analyzed by ANOVA for mean comparison and partial correlations, corrected for gestational age using SPSS 20.0. Sixty-two (62) IUGR fetuses between 24 and 37 weeks of gestation were compared to a population of normals, matched for gestational age. The systolic nadir of the AoI started to be retrograde at 26w in the IUGR group, compared to 31w in the normals. From 29w, the ISI became significantly lower in the IUGR group (F = 9.61, p = 0.021); this difference remained significant up to 32w. The ITSI was significantly correlated to the MCAPI (r = −0.36, p = 0.008). With the appearance of a reverse flow in the isthmus of IUGR fetuses, the brain is partly perfused by poorly oxygenated red cells turning in circle, both in systole and diastole. From the aortic isthmus towards aortic arch, brain, superior vena cava, right atrium and ventricle, ductus arteriosus and back to the isthmus, without the benefit of passing through the placenta. The relation between this “isthmic-brain hypoxic circle” and the incidence of abnormal post-natal neurodevelopmental sequellae deserves further investigations. This investigation (Placental Insufficiency and Aortic isthmus flow, The PIAF study) was supported by a research grant from the Canadian Institute for Health Research (CIHR); grant#MOP-97986.

Objective: Intrauterine growth restriction (IUGR) and prenatal exposure to oxidative stress are thought to lead to increased risks of cardiovascular disease later in life. The objective of the present study was to document whether cord blood oxidative stress biomarkers vary with the severity of IUGR and of vascular disease in the twin pregnancy model in which both fetuses share the same maternal environment.Methods: This prospective cohort study involved dichorionic twin pairs, with one co-twin with IUGR. Oxidative stress biomarkers were measured in venous cord blood samples from each neonate of 32 twin pairs, and compared, according to severity of IUGR (IUGR <5th percentile), Doppler anomalies of the umbilical artery and early onset IUGR (in the second trimester) of the growth restricted twin.Results: Oxidized Low-Density Lipoproteins (oxLDL) and Malondialdehyde (MDA) concentrations were increased proportionally in cases of severe IUGR. OxLDL concentrations were also increased in cases of IUGR with Doppler anomaly.Conclusion: Our data indicate that severe IUGR, is related to a derangement in redox balance, illustrated by increased venous cord blood oxidative stress biomarkers concentrations. Severe IUGR and IUGR with abnormal Doppler can be translated into conditions with intense oxidative stress.

Mesenchymal hamartoma of the chest wall is a rare, benign chondro-osseous tumor of the bone. Although it most commonly presents at birth or soon after, prenatal detection is rare. We report a case of prenatally detected mesenchymal hamartoma, and provide the rationale, details, and outcomes of our management. The literature is reviewed, with particular attention to prenatal detection and postnatal management options.

Intrauterine growth restriction and prenatal exposure to oxidative stress are thought to lead to increased risks of cardiovascular disease later in life. A prior study comparing the levels of oxidative stress biomarkers in the cord blood of 32 twin pregnancies with one co-twin with IUGR provided evidence of an impairment of the redox status in growth-restricted foetuses. The objective of the present study is to assess whether cord blood oxidative stress biomarkers vary with the severity of IUGR and of vascular disease in the twin pregnancy model in which both foetuses share the same maternal environment. This prospective cohort study involves twin pairs, with one co-twin with IUGR (< 10th percentile). Malondialdehyde (MDA) and oxidized low-density lipoproteins (oxLDL) were measured in venous cord blood samples. We verified whether there was an association between the severity of IUGR, IUGR with abnormal umbilical Doppler and early onset IUGR, and the concentrations of the biomarkers. Intra-pair comparisons of the 2 biomarkers were performed in using the Wilcoxon test for paired variates and group comparisons. Cord blood oxLDL concentrations were increased in cases of severe IUGR (P = 0.01), severe IUGR subjects with Doppler anomaly (P = 0.003) but not in those with early IUGR (P = 0.069). MDA was however increased only in the severe IUGR group (P = 0.036). Our data indicate that severe IUGR, but not early onset IUGR, is related to a derangement in redox balance, illustrated by increased venous cord blood oxLDL concentrations and to a lesser extent by MDA concentrations. IUGR with abnormal Doppler of the umbilical artery can be translated into conditions with intense oxidative stress. OC23.01: Table

Amniotic fluid ‘sludge’ (AFS) has been linked to intraamniotic infection, increased rates of spontaneous preterm delivery, PPROM and short interval from ultrasound diagnosis to delivery. This observational pilot study aims to determine if management with broad-spectrum antibiotics and progesterone initiated at diagnosis could delay delivery in patients incidentally found to have extremely premature cervical shortening and the presence of AFS. From 2008 to 2010, 42 patients were diagnosed with extremely premature cervical shortening (⩽ 15 mm) at routine ultrasound between 18–24 weeks' gestation. Ten patients were excluded because of multiple pregnancy or fetal anomaly. The presence of AFS was identified in 17 of the 32 patients and these women were managed uniformly with bed rest, broad-spectrum antibiotics and progesterone initiated at diagnosis and followed prospectively until delivery. Patients without AFS did not receive antibiotics. Mean gestational (GA) at diagnosis was 21.4 ± 1.9 weeks. The mean GA at delivery was 31.9 ± 6.0 (range 23.0–40.6) for patients without AFS and 35.1 ± 6.9 (range 21.9–41.4) weeks for patients with AFS (P = 0.16). The median delay from ultrasound diagnosis to delivery was 9.8 ± 6.2 (range 1.14–19.0) for patients without AFS and 14.3 ± 6.6 weeks (range 1.9–17.7) for patients with AFS. Though limited by small sample size, it appears that the outcome for women with very premature cervical changes and AFS treated with antibiotics and progesterone does not differ from those women with premature cervical changes without ‘sludge’. Antibiotic and progesterone therapy may improve outcome in these women who have been shown to have a very poor prognosis when treated expectantly or with cerclage. Future studies involving multiple centers are needed to better answer this question.

Objective We verified whether oxidative stress indices (oxidized low-density lipoproteins and malondialdehyde) and inflammatory biomarkers (circulating C-reactive protein, interleukin-6, tumour necrosis factor-α, serum amyloid A and soluble intercellular vascular cell adhesion molecule) are increased in the umbilical vein of placental insufficiency induced intra-uterine growth restricted neonates. Study design The prospective cohort study, involving 3 tertiary care centers, consists of 200 consecutively recruited pregnant women carrying twins. We chose the twin pregnancy model because both fetuses share the same maternal environment, thereby avoiding potential confounding factors when comparing oxidative stress and inflammation biomarkers. We analysed only twin pairs with one with intra-uterine growth restriction (N = 38) defined as fetal growth < 10th percentile with abnormal Doppler of the umbilical artery. Blood samples were taken at birth from the umbilical vein. Intra-pair comparisons on the biomarkers were performed using the Student paired t-test. Results We observed increased cord blood levels of oxidized low-density lipoproteins, (2.394 ± .412 vs 1.296 ± .204, p = .003) but not of malondialdehyde in growth restricted neonates when compared to their normal counterparts. Although indices of inflammation tended to be increased in cord blood from growth restricted newborns, the difference did not reach statistical significance. Conclusion In the twin model, intra-uterine growth restriction is associated with low-density lipoprotein oxidation without apparent dysregulation of inflammation biomarkers. Condensation Increased oxidized low-density lipoproteins are observed in growth restricted twins compared to their co-twins with normal growth at birth.

Objective: The purpose of this study was to assess the accuracy of sonographic prediction of twin birth weight discordance using the abdominal circumference ratio.Study design: This was a prospective cohort of diamniotic twin gestations that underwent serial ultrasound examinations every 2 to 4 weeks from 11 to 38 weeks or gestation. Birth weight discordance was defined as 25% difference in birth weight, relative to the larger twin. The sensitivity. specificity, and predictive values for the abdominal circumference ratio were assessed for the prediction of growth discordance.Results: Of 503 diamniotic twin pregnancies. 64 pregnancies (12.1%) had discordant fetal growth. The abdominal circumference ratio could be measured consistently throughout gestation in 100% of twin pairs. Receiver operating curve analysis showed that the abdominal circumference ratio was a good predictor of birth weight discordance (area under the Curve = 0.80). An abdominal circumference ratio cutoff of 0.93 yielded a sensitivity and specificity of 61% and 84%. respectively.Conclusion: Twin birth weight discordance may be predicted at any gestational age with an abdominal circumference ratio <0.93. (C) 2005 Elsevier Inc. All rights reserved.

To evaluate the effect of chorionicity on the pattern of discordant fetal growth in a large cohort of monochorionic (MC) and dichorionic (DC) twin pairs. A prospective cohort encompassing all cases of prenatally diagnosed twin gestations followed through to delivery from 1997 to 2002. Serial ultrasound examinations were performed at 2- to 4-week intervals. Chorionicity was determined by standard sonographic criteria in early pregnancy. The estimated fetal weight (EFW) was obtained from Arbuckle tables using abdominal circumference and femur length measurements. Discordance was determined by dividing the difference between the EFWs of the twins by the EFW of the larger twin (×100%). The direction and rate of change of discordance as a continuous variable was estimated for both MC and DC twin pairs using SAS MIXED procedure for repeated measures. A variance-covariance structure was modeled prior to fixed effect estimating. The interaction between gestational age and chorionicity was also tested. 503 consecutive twin pairs were studied, excluding all cases of twin-twin transfusion and monoamniotic twin pregnancies. Analysis was based on 1839 ultrasound exams performed after 19 weeks' gestation. Actual twin birth weight discordance of 25% or greater was present in 19% (24/125) of MC and 11.5% (43/378) of DC twins. Although the pattern of discordance was the same for both MC and DC twin pairs, the gestational age at onset was earlier in MC twins. Fetal weight discrepancy increased throughout gestation in both MC and DC twins (0.1% per week, P = 0.02); however, a significant difference (P<0.0001) was observed for intercept value between MC and DC twins (the linear equation for MC twins was estimated at 10%±0.1% per week versus 4%±0.1% per week in DC twins). The interaction between gestational age and chorionicity was not significant. Discordance in MC twins tends to occur earlier in gestation and remains increased at a 6% faster rate throughout gestation, as compared to DC twins.