OBJECTIVES:Testing for placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) is known to reduce time to diagnosis of preeclampsia and identify patients at increased risk of adverse perinatal outcomes. We implemented testing of sFlt-1/PlGF and sought to compare the time to diagnosis of preeclampsia before and after implementation, as well as selected outcomes and estimated costs. METHODS:Singleton pregnancies between 200 and 346 weeks gestation with suspected preeclampsia or placental dysfunction were identified by the hospital databases retrospectively from 2019 to 2021 and prospectively after implementation of sFlt-1/PlGF from 2022 to 2023. Outcomes were compared using negative binomial and Poisson regression models with entropy balancing to adjust for confounding. RESULTS:Before and after the implementation of sFlt-1/PlGF testing, a total of 494 and 145 patients were identified, respectively. Among the 206 patients with confirmed preeclampsia, those identified after implementation had an earlier mean gestational age at the time of diagnosis (31.8 weeks vs. 33.1 weeks, P = 0.001). The post-implementation cohort had a higher risk of neonatal intensive care unit admission ≥24 hours (risk ratio 3.85; 95% CI 2.07-7.17). All fetal deaths (5.0%) recorded after implementation had a positive sFlt-1/PlGF result. CONCLUSION:Among patients with suspected preeclampsia, sFlt-1/PlGF testing did not decrease the time to diagnosis of preeclampsia; it was associated with an earlier gestational age at time of diagnosis, identified patients with increased risk of neonatal intensive care unit admission and adverse fetal outcomes, and supports optimization of access to biochemical marker testing in regional centres.

BACKGROUND:Lateral quadratus lumborum block (QLB) is a potential alternative to intrathecal morphine (ITM) for analgesia after Caesarean delivery. We compared quality of recovery (QoR) and analgesia with lateral QLB, ITM, or ITM+QLB. METHODS:In this randomised, double-blind, placebo-controlled trial, women undergoing Caesarean delivery under spinal anaesthesia were allocated to (1) bilateral lateral QLB with 20 ml 0.5% ropivacaine; (2) 100 μg preservative-free ITM with sham QLB; or (3) ITM+QLB. The primary outcome was the QoR-40 score at 24 h. Secondary outcomes included pain scores, opioid consumption, and adverse effects. Given three-group comparisons, statistical significance was set at P<0.017. RESULTS:Fifty-eight women were analysed. Noninferiority testing for QoR-40 at 24 h between ITM and QLB was inconclusive (mean difference -0.9; 90% confidence interval [CI] -0.9 to 13.5). QLB reduced the resting pain score at 6 h compared with ITM (mean difference 2.9 [95% CI 1.3, 4.5]; P<0.001). Compared with ITM alone, ITM+QLB reduced the resting pain at 6 h (mean difference 3.3 [1.9, 4.8]; P<0.001), coughing pain at 6 h (3.0 [1.4, 4.7]; P<0.001), and worst pain at 24 h (1.8 [0.6, 3.1]; P=0.006). Oxycodone consumption and nausea or vomiting did not differ between groups. Pruritus was more frequent with QLB and ITM+QLB compared with ITM alone but was predominantly mild. CONCLUSIONS:Noninferiority of QLB vs ITM for QoR-40 at 24 h was inconclusive. However, QLB reduced early resting pain vs ITM, whereas ITM+QLB further reduced early resting and coughing pain and worst pain at 24 h vs ITM alone. Larger trials are needed to confirm these findings. CLINICAL TRIAL REGISTRATION:NCT02871713 (https://clinicaltrials.gov/study/NCT02871713).

OBJECTIVE:Ultrasound findings of fetal edema may provide early evidence of a genetic disorder. Our objective was to evaluate the frequency and diagnostic yield of sequencing in a selected population after a non-diagnostic microarray result for fetal edema. METHOD:Fetal edema (nuchal translucency > 3.5 mm, cystic hygroma, hydrops, other types) cases referred for genetic testing (2014-2022) were identified in our laboratory information system. Chart review confirmed associated ultrasound findings, findings from other imaging or pathology, multidisciplinary review, and genetic test utilization. Descriptive analyses determined diagnostic yields. RESULTS:There were 114 fetal edema cases with a non-diagnostic microarray result. Multidisciplinary review occurred in 79 (83%) cases, with targeted genes, gene panels, and/or exomes performed in 51 (54%) cases based on clinical assessment. Diagnoses were made in 17 (34%, with 59% providing a recurrence risk of ≥ 25%). RASopathy testing and exomes (with selective criteria) resulted in diagnostic yields of 18.5% and 41.2%, respectively. The highest diagnostic yields were in cases with fetal hydrops and other types of fetal edema (restricted to one body cavity). CONCLUSION:Review of additional testing beyond CMA in this cohort did not attempt to assess the overall yield of sequencing; instead, the study used a selected approach in which cases of fetal edema underwent further testing beyond CMA. In cases with cystic hygroma or increased nuchal translucency, RASopathy panel sequencing provides a good diagnostic yield, and should be offered as standard of care with CMA. Correlation of new and developing prenatal and postnatal findings, along with multidisciplinary team review, may inform additional testing, counseling and pregnancy management options, and is particularly important to consider in cases presenting with non-immune fetal hydrops.

DIVULGATIONS:Des déclarations ont été reçues de tous les auteurs. Aucune relation ou activité susceptible d'entraîner un conflit d'intérêts n'a été déclarée. Tous les auteurs ont indiqué qu'ils satisfaisaient aux exigences de la revue en matière d'auteur. MOTS CLéS: Consommation de substances ; grossesse ; soins virtuels ; télémédecine ; trouble lié à la consommation de substances CATéGORIES THéMATIQUES: Médecine fœto-maternelle ; obstétrique Ce document reflète les avancées cliniques et scientifiques émergentes à la date de publication et est susceptible d'être modifié. Les informations qu'il contient ne visent pas à imposer un traitement ou une procédure exclusive. Les établissements sont libres de modifier les recommandations. La SOGC suggère toutefois qu'ils documentent de manière adéquate toute modification apportée. CONSENTEMENT éCLAIRé: Les patientes ont le droit et la responsabilité de prendre des décisions éclairées concernant leurs soins, en partenariat avec leur professionnel de la santé. Afin de faciliter le choix éclairé, les patientes doivent être informées et soutenues basé sur les preuves, adapté à leur culture et personnalisé. Leurs valeurs, leurs croyances, leurs besoins individuels et leur situation personnelle doivent être pris en compte, et la décision finale choisie par la patiente concernant les options de soins et de traitement doit être respectée. LANGAGE ET INCLUSIVITé: La SOGC reconnaît l'importance de l'inclusivité et, lorsque le contexte de le permet, un langage neutre sera utilisé. Parfois, nous utiliserons un langage genré en raison de notre mission de promotion de la santé des femmes. La SOGC reconnaît et respecte les droits de toutes les personnes auxquelles les informations contenues dans ce document peuvent s'appliquer, y compris, mais sans s'y limiter, les personnes transgenres, non binaires et intersexuées. La SOGC encourage les professionnels de la santé à engager un dialogue respectueux avec leurs patients au sujet de leur identité de genre et des pronoms qu'ils préfèrent, et à appliquer ces lignes directrices en adoptant une approche sensible et centrée sur le patient. NOTATION DES SEMAINES DE GESTATION:Les auteurs suivent la notation de l'Organisation mondiale de la santé concernant l'âge gestationnel: le premier jour des dernières règles correspond au jour 0 (de la semaine 0); par conséquent, les jours 0 à 6 correspondent à la semaine 0 complète, les jours 7 à 13 correspondent à la semaine 1 complète, etc.

Objective To provide health care providers with the best evidence for using virtual models of care for pregnant or post-partum patients using substances. Target Population The target population includes all women with a history of substance use, current substance use disorder, or risk of substance use disorder during pregnancy or the post-partum period. Outcomes Improved access, engagement, and continuity of care for individuals affected by substance use during the perinatal period through the integration of virtual care models into clinical practice. Benefits, Harms, and Costs Virtual care offers enhanced accessibility, reduced stigma, and greater flexibility, particularly for underserved populations. However, challenges include variable access to technology, privacy concerns, and the need for provider training. The cost of implementing digital infrastructure may be offset by long-term improvements in maternal and neonatal outcomes. Evidence This technical update is based on a systematic review of current literature evaluating the effectiveness, acceptability, and feasibility of virtual care for substance use and substance use disorder in pregnancy. Studies covered clinical outcomes, patient engagement, provider experiences, and system-level considerations from 2015 to 2025. Validation Methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations). Intended Audience All health care providers who care for pregnant and/or post-partum women. X Abstract Virtual care improves access to substance use treatment during pregnancy. Hybrid models of care reduce stigma, enhance engagement, and improve outcomes.

BACKGROUND:Worsening neonatal outcomes over time among planned vaginal births following a previous cesarean were reported in Canada; what drove the change remained unclear. OBJECTIVE:We aimed to describe time trends in severe maternal and perinatal-neonatal morbidity associated with a planned vaginal birth vs a repeat cesarean after a previous cesarean delivery and identify risk factors associated with the trends. STUDY DESIGN:This population-based cohort study included all singleton births ≥37 weeks' gestation from Nova Scotia, Canada, April 1, 2003 to March 31, 2021 with 1 previous cesarean and without trial of labor contraindications. Primary outcomes were severe maternal morbidity and severe perinatal-neonatal morbidity. Adjusted risk ratios and 95% confidence intervals were estimated using log-binomial regression, accounting for confounding using inverse probability weighting. RESULTS:Among 12,681 births (4% aged ≥40 years), 5138 (40.5%) had a planned vaginal birth. Among those with a planned vaginal birth vs a repeat cesarean, severe maternal morbidity increased over time, from 5.9 vs 5.0 per 1000 deliveries in 2003-2008 (adjusted risk ratio, 1.13; 95% confidence interval, 0.46-2.8) to 17.3 vs 4.3 per 1000 deliveries in 2015-2021 (adjusted risk ratio, 3.4; 95% confidence interval, 1.38-8.2). In addition, severe perinatal-neonatal morbidity increased over time from 10.6 vs 10.0 per 1000 deliveries in 2003-2008 (adjusted risk ratio, 1.18; 95% confidence interval, 0.60-2.3) to 25.1 vs 17.2 per 1000 deliveries in 2015-2021 (adjusted risk ratio, 1.56, 95% confidence interval, 0.98-2.5). Any oxytocin induction or augmentation of labor increased from 12.1% in 2003-2008 to 37.9% in 2015-2021; its use was strongly associated with severe maternal morbidities in 2015-2021. CONCLUSION:Planned vaginal birth vs a repeat cesarean after a previous cesarean delivery was more strongly associated with severe maternal and perinatal-neonatal morbidity in later years. Oxytocin induction and augmentation increased markedly in this population and could not be ruled out as a factor associated with worsening outcomes.

BACKGROUND:The objective of this study was to examine the association of birth by Caesarean section (CS) with female offspring's risk of CS delivery. METHODS:We used data from the 3G Multigenerational Cohort, which includes women whose births and their own subsequent pregnancies and deliveries were recorded in the population-based Nova Scotia Atlee Perinatal Database. The current analysis was limited to the women's first delivery (n = 23,605). Confounding variables were identified using a directed acyclic graph. The association between birth by CS and later CS delivery was examined with Poisson regression adjusted for confounding variables. RESULTS:Seventeen percent of women were born via CS, and 23 % delivered by CS. Compared to women born vaginally, women born by CS had an adjusted relative risk (RR) of 1.36 (95 % confidence interval [CI] 1.30, 1.43) for delivering by CS. Restricting the sample to women born to nulliparous mothers did not change the association (RR 1.35), while restriction to women born out of low-risk pregnancies weakened it slightly (RR 1.25). CONCLUSIONS:Birth by CS is associated with a 36 % increased risk of women delivering their first child by CS. This increase is likely due to shared medical and socio-cultural factors.

The objectives of this study were to examine the total effect of grandmaternal (G0) prepregnancy body mass index (BMI) on infant (G2) birthweight z score and to quantify the mediation role of maternal (G1) prepregnancy BMI. Data were extracted from the Nova Scotia 3G Multigenerational Cohort. The association between G0 prepregnancy BMI and G2 birthweight z score and the mediated effect by G1 prepregnancy BMI were estimated using g-computation with adjustment for confounders identified using a directed acyclic graph and accounting for intermediate confounding. A total of 20 822 G1-G2 dyads from 18 450 G0 participants were included. Relative to G0 normal weight, G0 underweight decreased mean G2 birthweight z score (-0.11; 95% CI, -0.20 to -0.030), whereas G0 overweight and obesity increased mean G2 birthweight z score (0.091 [95% CI, 0.034-0.15] and 0.22 [95% CI, 0.11-0.33], respectively). G1 prepregnancy BMI partly mediated the association, with the largest effect size observed for G0 obesity (0.11; 95% CI, 0.080-0.14). Estimates of the direct effect were close to the null. In conclusion, grandmaternal prepregnancy BMI was associated with infant birthweight z score. Maternal prepregnancy BMI partly mediated the association, suggesting that factors related to BMI may play an important role in the transmission of weight across the maternal line.

Prediction of small (SGA) and large for gestational age (LGA) using routinely collected antenatal data remains suboptimal, particularly among nulliparous women. In this study, models for SGA (< 10th percentile) and LGA (> 90th percentile) were developed by combining grandmaternal pregnancy-related information and maternal birth characteristics ("G0 predictors") with maternal clinical factors available at 26 weeks' gestation ("G1 predictors"). The study used a cohort of first-born, singleton births to nulliparous women in Nova Scotia, Canada (1981-2011), and their mothers, from the Nova Scotia Atlee Perinatal Database. Models using G0 predictors, G1 predictors, and their combination were developed with Super Learner, an ensemble machine learning algorithm, and internally validated using nested cross-validation. Discrimination was assessed via the area under the receiver operating characteristic curve (AUC-ROC) and the precision-recall curve (AUC-PR); calibration was also evaluated. Among 9,097 grandmother-mother-infant triads, 902 (9.9%) infants were SGA and 891 (9.8%) were LGA. Including G0 predictors improved discrimination compared to G1-only models (AUC-ROC 0.69 vs. 0.66 for SGA and 0.71 vs. 0.66 for LGA; AUC-PR: 0.21 vs. 0.18 for SGA and 0.22 vs. 0.18 for LGA). Models fitted using both sets of predictors were well calibrated. While incorporating intergenerational information modestly improved prediction, overall predictive performance remains poor.

Background: Previous literature suggests that pregnant individuals with obesity have fewer planned and successful vaginal births following a previous cesarean delivery. Concern is growing that discrimination based on body mass index (BMI) and comorbidities associated with BMI, rather than BMI itself, are primarily responsible for these findings. Objective: To describe disparities in planning and having a successful vaginal delivery after a previous cesarean delivery by BMI status. Study Design: This population-based cohort study included all singleton pregnancies ≥37 weeks’ gestation from 2003 to 2021 in Nova Scotia, Canada, with one previous cesarean and without contraindications for a trial of labor. Adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) were estimated using Poisson regression, incorporating inverse probability weighting to account for confounding by demographic characteristics and co-morbidities. Results: Among 12 646 deliveries, approximately 31% experienced pre-pregnancy obesity. Of those with obesity, 34% planned a vaginal birth compared to 44% of those without obesity (aRR: 0.82, 95% CI: 0.78, 0.86). Higher BMI classification was associated with a reduced likelihood of planned vaginal delivery: class I: 37%, aRR: 0.88 (95% CI: 0.82, 0.94); class II: 32%, aRR: 0.81 (95% CI: 0.74, 0.89); class III: 26%, aRR 0.65 (95% CI: 0.56, 0.75). Among those planning a vaginal delivery, those with obesity were less likely to have a vaginal birth compared to those without obesity (57% vs 69%; aRR: 0.87, 95% CI: 0.82, 0.92); successful vaginal birth was less likely as BMI increased. Conclusion: Obesity was associated with reduced planned and successful vaginal delivery after a previous cesarean delivery and the association was most pronounced at higher BMI after accounting for demographic characteristics and co-morbidities. While discrimination based on BMI was unmeasured, notable disparities in planning and having a vaginal delivery by BMI suggest that training for health care providers and the availability of appropriate infrastructure may help optimize care for this population.

OBJECTIVE:To investigate the performance of targeted gene sequencing, expanded gene panels, and selected exomes for prenatally identified fetal anomalies, after non-diagnostic microarray results. METHOD:All fetal samples received for genetic testing for fetal structural anomalies in the Canadian Maritime Provinces (2014-2022) were identified. Utilization and results of NGS sequencing strategies after a non-diagnostic microarray were correlated with ultrasound findings and autopsy results. RESULTS:Five hundred and ninety-three cases of fetal anomalies with non-diagnostic RAD results were identified, including 319 (54%) with isolated anomalies. Diagnostic yield from the microarray was 7.5%. Sequence-based testing for 131 cases gave an overall diagnostic yield of 38% (8.4% of initial cohort). For isolated anomalies, diagnostic yield was highest in the intracranial, renal, and musculoskeletal systems (44%, 60%, 64% respectively). Appropriate targeted gene sequencing provided a diagnostic yield of 40%. With clinically indicated criteria for exome analysis, diagnostic yields were higher than when clinical information prompted use of a selected gene panel (73% vs. 27%). Expanding to an exome after a non-diagnostic gene panel had an additional diagnostic yield of 13%. CONCLUSION:Multidisciplinary review and comprehensive clinical information can inform the selection of strategies for expanded genetic testing after non-diagnostic microarray for fetal anomalies within a publicly funded health care system.

Although the association between the prolonged second stage of labour and obstetrical anal sphincter injury (OASI) risk has been established, the contribution of the duration of the active phase (time spent pushing) remains unclear. This study was aimed at estimating the association between the duration of the active phase of the second stage of labour and OASI risk among nulliparous pregnant persons. We conducted a population-based, retrospective cohort study of nulliparous pregnant persons who gave birth to a singleton, non-anomalous, vertex foetus at ≥ 37 weeks’ gestational age from 2017 to 2021. Poisson regression models adjusting for confounders were developed to estimate the risk ratio (RR) with 95

BACKGROUND:Counseling on the harms and benefits of a planned vaginal versus a planned repeat cesarean delivery often relies on observational studies using routinely collected (or administrative) data. However, the accuracy of planned (rather than actual) mode of delivery classifications in such data remains unknown. This study aimed to evaluate the validity of an administrative data-based algorithm to identify planned vaginal and planned cesarean deliveries among individuals with a previous cesarean. METHODS:An algorithm based on diagnostic and procedural codes was applied to records from the Nova Scotia Atlee Perinatal Database. Included were individuals with a previous cesarean eligible for a trial of labor between 2017 and 2019. We compared the classification of planned mode of delivery using the algorithm with that determined through review of a random sample of 200 medical charts. We estimated sensitivity, specificity, and predictive values with 95% confidence intervals (CIs). RESULTS:Based on the chart review, 80 deliveries (40%) were planned vaginal deliveries. The algorithm had an estimated sensitivity of 99% (95% CI: 93%, 100%), specificity of 96% (95% CI: 91%, 99%), positive predictive value of 94% (95% CI: 87%, 98%), and negative predictive value of 99% (95% CI: 95%, 100%) for identifying planned vaginal deliveries. CONCLUSIONS:An algorithm based on routinely collected data accurately classified planned vaginal and planned cesarean deliveries among individuals with a previous cesarean. These findings suggest that studies using similar algorithms to inform counseling on planned mode of delivery in this population are minimally impacted by misclassification of this data.

OBJECTIVES:To describe annual trends in the incidence of stillbirth and infant mortality in Nova Scotia over a 35-year period. METHODS:A population-based cohort study of deliveries between 1988 and 2022 was conducted using data from the provincial, clinically oriented Nova Scotia Atlee Perinatal Database. All pregnancies ≥200 weeks gestation or ≥500 g were included. Rates of fetal death (per 1000 births) and neonatal and infant mortality (per 1000 live births) were calculated by birth year. Rates were reported for the entire cohort and stratified by birth parent age, birthweight for gestational age and sex, and number of fetuses. RESULTS:A total of 334 776 deliveries were included, with 332 975 of these being live births; there were 1801 stillbirths, 1082 neonatal deaths, and 1579 infant deaths. Rates of fetal, neonatal, and infant death decreased between 1988-1992 and 2018-2022 (6.8-4.8, 4.0-2.5, and 6.3-4.0 per 1000 births, respectively). Rates increased somewhat in later 5-year epochs among those ≥35 years of age. Rates in the <10th percentile of birthweight for gestational age were highest in earlier epochs and showed a general downward trend with each epoch except the last. Marked temporal reductions in rates among multiple gestations were observed. CONCLUSIONS:Increases in mortality in later epochs, and among select birth parents and infant factors, suggest that patient characteristics and clinical practice changes may play a role in these increases. The observed temporal changes are important in informing the evaluation of factors associated with stillbirth and infant mortality.

Objectives: Some evidence suggests that infants born at later gestational age (GA) are at higher risk of developing neonatal abstinence syndrome (NAS). This systematic review estimated the association between GA at delivery and development of NAS in infants born to women on opioid agonist therapy (OAT). Methods: MEDLINE/PubMed, Scopus, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials were searched from January 2000 to April 2023. Studies reporting data on the association between GA and NAS among pregnant women being treated with OAT were eligible for inclusion. Random effects meta-analysis was used to estimate the mean difference in GA between infants affected by NAS and unaffected infants; odds ratio (OR) for the association between preterm birth and NAS; and OR for the association between gestational week and NAS. Results: Of 966 records identified, 38 studies were eligible for this review. The pooled mean difference in GA between infants affected by NAS and unaffected infants was 0.62 weeks (95% CI: 0.08–1.16, I2=90.7%). The odds of developing NAS were estimated to increase by 3% per gestational week (OR 1.03, 95% CI: 0.997-1.06, I2=84.2%). The OR for the association between preterm birth and developing NAS was estimated to be 0.87 (95% CI: 0.63-1.21, I2=85.7%). Conclusions: The data included in this review demonstrate that higher GA is unlikely to be associated with an increased risk of NAS, although poor study quality and significant study heterogeneity were observed.

OBJECTIVES:Clinical practice guidelines recommend determining gestational age (GA) for twin pregnancies using the fetal crown rump length (CRL) of the larger fetus. This study investigated whether the CRL of the larger or smaller fetus at 11-14 weeks best predicted in vitro fertilization (IVF) assigned GA. METHODS:A retrospective cohort study of twin pregnancies conceived by IVF ± intracytoplasmic sperm injection, 2004-2022, generated GA estimations for each co-twin CRL at the 11-14 week ultrasound, to determine which fetus (smaller or larger) more consistently predicted IVF-assigned GA. Monoamniotic twins and twins with known structural or vascular abnormalities were excluded. Paired t tests evaluated the ability of CRL to predict GA, and logistic regression evaluated the predictive ability of each of the co-twin groups with increasing size differences. Statistical significance was set at P < 0.05. RESULTS:Viewpoint 6 identified 359 eligible twin pairs. CRL was closest with the smaller fetus (0.38 days); CRL for both the smaller (95% CI 0.16-0.61) and the larger (2.25 days, 95% CI 2.04-2.46) fetus showed deviation from IVF-assigned GA. As the absolute difference between the small and large fetus increased, the ultrasound-estimated GA of the smaller fetus was still consistently closer to IVF-assigned GA. CONCLUSIONS:In this selected population of twins with known GA, the CRL of the smaller fetus more accurately predicted IVF-assigned GA even with increasing differences in fetal size. These findings provide important information for appropriately dating pregnancies to facilitate adherence to national guidelines to monitor for pregnancy complications, and plan frequency and type of fetal surveillance, as well as timing of delivery.

Obesity does not contraindicate a trial of labour after a previous cesarean section (TOLAC), but it is unclear whether pregnant individuals with obesity experience fewer TOLACs. Our objective is to assess whether pregnant individuals with obesity were less likely to undergo a TOLAC and have a successful vaginal birth after cesarean section (VBAC) than those without obesity.

Among infants exposed to opioids during pregnancy, those born at earlier gestational ages may have a decreased risk for Neonatal Abstinence Syndrome (NAS). The objective was to investigate the association between gestational age at delivery and the development of NAS requiring pharmacotherapy.