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Aflaki K, Ray JG, Edwards W, Scott H, Arbour L, Darling EK, Moore A, Dzakpasu S. Maternal Deaths by Suicide and Drug Overdose in Two Canadian Provinces; Retrospective Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102581. [PMID: 38852810 DOI: 10.1016/j.jogc.2024.102581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/03/2024] [Accepted: 05/15/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVES To identify and review factors associated with maternal deaths by suicide and drug overdose in the Canadian Coroner and Medical Examiners Database, from 2017 to 2019. METHODS We identified potential maternal deaths in Ontario and British Columbia by searching the Canadian Coroner and Medical Examiners Database narratives of deaths to females 10 to 60 years old for pregnancy-related terms. Identified narratives were then qualitatively reviewed in quadruplicate to determine if they were maternal deaths by suicide or drug overdose, and to extract information on maternal characteristics, the manner of death, and factors associated with each death. RESULTS Of the 90 deaths identified in this study, 15 (16.7%) were due to suicide and 20 (22.2%) were due to a drug overdose. These deaths occurred in women of varying ages and across the pregnancy-postpartum period. Among the suicides, 10 were by hanging, and among the overdose-related deaths, 15 had fentanyl detected. Notably, 13 (37.1%) of the 35 deaths to suicide or drug overdose occurred beyond 42 days after pregnancy, 19 (54.3%) followed a miscarriage or induced abortion, and in 23 (65.7%) there was an established history of mental health illness. Substance use disorders were documented in 4 of the 15 suicides (26.7%), and 18 of the 20 overdose-related deaths (90.0%). CONCLUSIONS Suicide and drug overdose may contribute more to maternal deaths in Canada than previously realized. Programs are needed to identify women at risk of these outcomes and to intervene during pregnancy and beyond the conventional postpartum period.
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Affiliation(s)
- Kayvan Aflaki
- Institute of Medical Science, University of Toronto, Toronto, ON
| | - Joel G Ray
- Departments of Medicine, Health Policy Management and Evaluation, University of Toronto, Toronto, ON; Department of Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, ON
| | - Wesley Edwards
- Department of Anesthesia and Pain Medicine, The Ottawa Hospital, Ottawa, ON; Faculty of Medicine, University of Ottawa, Ottawa, ON
| | - Heather Scott
- Department of Obstetrics and Gynaecology, IWK Health Center, Dalhousie University, Halifax, NS
| | - Laura Arbour
- Department of Medical Genetics, University of Victoria, Victoria, BC
| | - Elizabeth K Darling
- McMaster Midwifery Research Centre, and Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON
| | - Aideen Moore
- Division of Neonatology, The Hospital for Sick Children, Toronto, ON
| | - Susie Dzakpasu
- Maternal and Infant Health Section, Public Health Agency of Canada, Ottawa, ON.
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Arya S, Mahar A, Callum J, Haspel RL. Examining Injustices: Transfusion Medicine and Race. Transfus Med Rev 2024; 38:150822. [PMID: 38519336 DOI: 10.1016/j.tmrv.2024.150822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 02/01/2024] [Accepted: 02/12/2024] [Indexed: 03/24/2024]
Abstract
Race and ethnicity are sociopolitical and not biological constructs, and assertions that these population descriptors have scientific meaning has caused significant harm. A critical assessment of the transfusion medicine literature is an important aspect of promoting race-conscious as opposed to race-based medicine. Utilizing current definitions and health equity frameworks, this review will provide a critical appraisal of transfusion medicine studies at the intersection of race and healthcare disparities, with a focus on larger methodological challenges facing the transfusion medicine community. Moving forward, risk modelling accounting for upstream factors, patient input, as well as an expert consensus on how to critically conduct and evaluate this type of literature are needed. Further, when using race and ethnicity in research contexts, investigators must be aware of existing guidelines for such reporting.
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Affiliation(s)
- Sumedha Arya
- Canadian Blood Services, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Alyson Mahar
- School of Nursing and Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Jeannie Callum
- University of Toronto, Toronto, Ontario, Canada; Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | - Richard L Haspel
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Lasry A, Adant S, Farag K, Tidafi C, Wareham C, Malick M, Roy-Lacroix MÈ, Morin PA, Sauvé N. A retrospective analysis of postpartum red blood cell transfusions at a tertiary care obstetric centre. Vox Sang 2024. [PMID: 38925649 DOI: 10.1111/vox.13702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/26/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND AND OBJECTIVES Postpartum anaemia is a prevalent health problem. We aimed to determine the compliance rate for red blood cell (RBC) transfusion indication among postpartum women in a single tertiary care centre in Quebec, Canada. MATERIALS AND METHODS Retrospective cohort study including all women ≥6 h postpartum who received ≥1 RBC transfusion during their delivery hospitalization between January 2005 and February 2022. We determined our centre's compliance rate by indication as compared to current society guidelines, all published after 2015 (Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis [NATA], Royal College of Obstetricians and Gynaecologists [RCOG], American College of Obstetricians and Gynecologists [ACOG]). We then explored predictors of guideline non-compliance and described transfusion practices in our centre. RESULTS A total of 171 women were included. Our centre's compliance rate was 79.5% (95% confidence interval [CI] 72.7-84.8). Predictors of guideline non-compliance were maternal medical comorbidity or abnormal placentation, both limited by large CIs (odds ratio [OR] 2.26, CI 1.02-4.94, p = 0.04; OR 4.00, CI 1.31-12.06, p = 0.01, respectively). Postpartum haemorrhage was diagnosed among 68% of the cohort, mostly due to uterine atony (73.3%). Mean baseline and nadir haemoglobin were 111 g/L (±18) and 62 g/L (±7.7), respectively. Multiple unit initial transfusion was found in a majority of patients (63.7%). Iron therapy was administered to 51.5% of women in-hospital and 81.9% received an oral iron prescription at discharge. There were no differences in primary or secondary outcomes subsequent to relevant guideline publication. CONCLUSION Our centre's compliance rate for RBC transfusion indication meets current practice guidelines. Areas for improvement include single-unit initial transfusion protocols and adjuvant iron treatment. Antenatal optimization of haemoglobin and ferritin stores may limit postpartum transfusions.
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Affiliation(s)
- Ariane Lasry
- Department of Obstetrics and Gynecology, University of Sherbrooke, Sherbrooke, Canada
| | - Samuel Adant
- Department of Medicine, Hematology-Oncology Division, University of Sherbrooke, Sherbrooke, Canada
| | - Karen Farag
- Faculty of Medicine, University of Sherbrooke, Sherbrooke, Canada
| | - Celya Tidafi
- Faculty of Medicine, University of Sherbrooke, Sherbrooke, Canada
| | | | - Mandy Malick
- Department of Medicine, Faculty of Medicine, University of Sherbrooke, Sherbrooke, Canada
| | - Marie-Ève Roy-Lacroix
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Division, University of Sherbrooke, Sherbrooke, Canada
| | - Pierre-Aurèle Morin
- Department of Medicine, Hematology-Oncology Division, University of Sherbrooke, Sherbrooke, Canada
| | - Nadine Sauvé
- Department of Medicine, Obstetrical and Internal Medicine Division, University of Sherbrooke, Sherbrooke, Canada
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Wang T, Li H, Liu Y, Min X. Quantitative blood loss measurement methods for early detection of primary postpartum haemorrhage following vaginal birth: A scoping review. J Clin Nurs 2024. [PMID: 38764248 DOI: 10.1111/jocn.17216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/09/2024] [Accepted: 05/07/2024] [Indexed: 05/21/2024]
Abstract
AIM To map the commonly used quantitative blood loss measurement methods in clinical practice and provide a solid foundation for future studies. DESIGN AND METHOD This study adhered to the JBI methodology for scoping reviews and preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews. We conducted a literature search using five databases to retrieve articles published between January 2012 and September 2022. The search was repeated on 29 February 2024. Data extraction and verification were carried out by two independent researchers using a self-designed data extraction form. RESULTS Ultimately, 26 studies published between 2012 and 2024 were considered eligible for inclusion. Six categories of methods were identified from the 26 articles. Among the included studies, only two involved randomized controlled trials, with the majority being observational studies. The World Health Organization (2012) version of the postpartum haemorrhage diagnostic criteria was predominantly used in most studies. Gravimetric and volumetric methods emerged as the most commonly used methods for quantifying postpartum haemorrhages. The timing of blood collection was inconsistent among the included studies. Only 12 studies mentioned measures for the management of amniotic fluid. CONCLUSIONS This scoping review supports the replacement of the visual estimation of blood loss with quantitative assessment methods. Supporting a specific assessment approach is not feasible due to the variability of the study. Future research should focus on establishing the best practices for specific quantitative methods to standardize the management of postpartum haemorrhage and reduce the incidence of postpartum haemorrhage-related adverse outcomes. RELEVANCE TO CLINICAL PRACTICE Healthcare professionals need to acknowledge the low accuracy of visual estimation methods and implement quantitative methods to assess postpartum blood loss. Given the limitations inherent in each assessment method, quantification of blood loss should be combined with assessment of maternal vital signs, physiologic indicators and other factors.
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Affiliation(s)
- Tong Wang
- Department of Nursing, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- School of Nursing, Shanghai Jiao Tong University, Shanghai, China
| | - Hong Li
- Department of Nursing, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- School of Nursing, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Liu
- Delivery Unit, Shanghai First Maternity and Infant Hospital, Tongji University, Shanghai, China
| | - Xiongkuo Min
- School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, China
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Ács N, Korte WC, von Heymann CC, Windyga J, Blatný J. Rationale for the Potential Use of Recombinant Activated Factor VII in Severe Post-Partum Hemorrhage. J Clin Med 2024; 13:2928. [PMID: 38792469 PMCID: PMC11122570 DOI: 10.3390/jcm13102928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/17/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024] Open
Abstract
Severe post-partum hemorrhage (PPH) is a major cause of maternal mortality worldwide. Recombinant activated factor VII (rFVIIa) has recently been approved by the European Medicines Agency for the treatment of severe PPH if uterotonics fail to achieve hemostasis. Although large randomized controlled trials are lacking, accumulated evidence from smaller studies and international registries supports the efficacy of rFVIIa alongside extended standard treatment to control severe PPH. Because rFVIIa neither substitutes the activity of a missing coagulation factor nor bypasses a coagulation defect in this population, it is not immediately evident how it exerts its beneficial effect. Here, we discuss possible mechanistic explanations for the efficacy of rFVIIa and the published evidence in patients with severe PPH. Recombinant FVIIa may not primarily increase systemic thrombin generation, but may promote local thrombin generation through binding to activated platelets at the site of vascular wall injury. This explanation may also address safety concerns that have been raised over the administration of a procoagulant molecule in a background of increased thromboembolic risk due to both pregnancy-related hemostatic changes and the hemorrhagic state. However, the available safety data for this and other indications are reassuring and the rates of thromboembolic events do not appear to be increased in women with severe PPH treated with rFVIIa. We recommend that the administration of rFVIIa be considered before dilutional coagulopathy develops and used to support the current standard treatment in certain patients with severe PPH.
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Affiliation(s)
- Nándor Ács
- Department of Obstetrics and Gynaecology, Semmelweis University, H-1082 Budapest, Hungary
| | - Wolfgang C. Korte
- Centre for Laboratory Medicine, Haemostasis and Haemophilia Centre, CH-9001 St. Gallen, Switzerland
| | - Christian C. von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum in Friedrichshain, DE-10249 Berlin, Germany
| | - Jerzy Windyga
- Department of Haemostasis Disorders and Internal Medicine, Laboratory of Haemostasis and Metabolic Diseases, Institute of Haematology and Transfusion Medicine, 02-776 Warsaw, Poland
| | - Jan Blatný
- Department of Paediatric Oncology, University Hospital Brno, and Masaryk University, 613 00 Brno, Czech Republic
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Fernandez MG, Coutinho de Carvalho SF, Martins BA, Santos FDSM, Neto FAFP, Medeiros MODA, Bastos Metzger P. Uterine Artery Embolization Versus Hysterectomy in Postpartum Hemorrhage: A Systematic Review With Meta-Analysis. J Endovasc Ther 2024:15266028241252730. [PMID: 38733296 DOI: 10.1177/15266028241252730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
PURPOSE The objective of this study is to perform a meta-analysis comparing the effectiveness of uterine artery embolization (UAE) versus peripartum hysterectomy for acute refractory postpartum hemorrhage (PPH) control. MATERIALS AND METHODS We systematically searched 6 medical databases for studies comparing UAE and hysterectomy in PPH. Outcomes examined were mortality, hospitalization duration (HD) in days, and red blood cells (RBC) units utilization. Statistical analysis used RevMan 5.1.7 and random-effects models. Odds ratios (OR) and mean differences (MDs) with 95% confidence intervals (CIs) were used for dichotomous and continuous outcomes, respectively. RESULTS We included 833 patients from 4 cohort studies, with 583 (70%) undergoing UAE. The UAE population required fewer RBC units (MD: -7.39; 95% CI: -14.73 to -0.04; p=0.05) and had shorter HD (MD: -3.22; 95% CI: -5.42 to -1.02; p=0.004). Lower mortality rates were noted for UAE in the pooled analysis, but no statistical significance. Uterine artery embolization demonstrated lower procedural complications (16.45% vs. 28.8%), in which UAE had less ureter and bladder lesions (OR: 0.05; 95% CI: 0.01-0.38; p=0.004 and OR: 0.02; 95% CI: 0.00-0.15; p<0.001, respectively). Only 35 (6%) required conversion to hysterectomy, while 27 (4.6%) underwent re-embolization with 100% bleeding control. Uterine artery embolization did not hinder fertility, with normal menstruation restored in 19 patients with postoligomenorrhea. CONCLUSION Uterine artery embolization for the control of PPH is associated with lower use of RBC units and HD, but similar rates of mortality are noted when compared to hysterectomy. These results associated with uterine preservation could support its importance for refractory PPH management. CLINICAL IMPACT Uterine Artery Embolization is associated with a shorter hospitalization duration and reduced use of red blood cell units when compared with hysterectomy in refractory postpartum hemorrhage. Although demonstrating similar mortality rates, these findings, together with fertility preservation, support the method incorporation as a valuable option in obstetric services.
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Tran A, Clarke G, Callum JL, Smith G, Somerset D, Thorne J, Lieberman L. Reconsidering Routine Repeat Group and Screens During Pregnancy-Personalizing Pregnancy Care. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102351. [PMID: 38199432 DOI: 10.1016/j.jogc.2024.102351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024]
Abstract
The group and screen (G&S) are performed in early pregnancy to identify clinically significant antibodies (CSA) that may necessitate fetal monitoring for hemolysis/anemia or affect RhIg eligibility. Guidelines vary, including differences between RhD-positive and negative patients, but typically, the G&S is repeated at 28 weeks, and sometimes pre-delivery. We reviewed data showing a low risk (0.01%-0.43%) of detecting a new CSA in late gestation (late alloimmunization) and the risk of late alloimmunization causing severe hemolysis/anemia is even lower at <0.01%. Routinely repeating a G&S at 28 weeks and delivery may not be necessary for healthy, low-risk pregnancies.
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Affiliation(s)
- Ann Tran
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC.
| | - Gwen Clarke
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB
| | - Jeannie L Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, ON; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON
| | - Graeme Smith
- Department of Obstetrics and Gynaecology, Kingston Health Sciences Centre, Queen's University, Kingston, ON
| | - David Somerset
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB
| | - Julie Thorne
- Department of Obstetrics and Gynaecology, Women's College Hospital, Sinai Health Systems and University of Toronto, Toronto, ON
| | - Lani Lieberman
- Laboratory Medicine Program, University Health Network, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON
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Yang Y, Shao Y, Chen H, Guo X, Liang Y, Wang Y, Zhao Y. Characteristics and treatment for severe postpartum haemorrhage in different midwifery hospitals in one district of Beijing in China: an institution-based, retrospective cohort study. BMJ Open 2024; 14:e077709. [PMID: 38569676 PMCID: PMC11146356 DOI: 10.1136/bmjopen-2023-077709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 12/08/2023] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE To identify the characteristics and treatment approaches for patients with severe postpartum haemorrhage (SPPH) in various midwifery institutions in one district in Beijing, especially those without identifiable antenatal PPH high-risk factors, to improve regional SPPH rescue capacity. DESIGN Retrospective cohort study. SETTING This study was conducted at 9 tertiary-level hospitals and 10 secondary-level hospitals in Haidian district of Beijing from January 2019 to December 2022. PARTICIPANTS The major inclusion criterion was SPPH with blood loss ≥1500 mL or needing a packed blood product transfusion ≥1000 mL within 24 hours after birth. A total of 324 mothers with SPPH were reported to the Regional Obstetric Quality Control Office from 19 midwifery hospitals. OUTCOME MEASURES The pregnancy characteristics collected included age at delivery, gestational weeks at delivery, height, parity, delivery mode, antenatal PPH high-risk factors, aetiology of PPH, bleeding amount, PPH complications, transfusion volume and PPH management. SPPH characteristics were compared between two levels of midwifery hospitals and their association with antenatal PPH high-risk factors was determined. RESULTS SPPH was observed in 324 mothers out of 106 697 mothers in the 4 years. There were 74.4% and 23.9% cases of SPPH without detectable antenatal PPH high-risk factors in secondary and tertiary midwifery hospitals, respectively. Primary uterine atony was the leading cause of SPPH in secondary midwifery hospitals, whereas placental-associated disorders were the leading causes in tertiary institutions. Rates of red blood cell transfusion over 10 units, unscheduled returns to the operating room and adverse PPH complications were higher in patients without antenatal PPH high-risk factors. Secondary hospitals had significantly higher rates of trauma compared with tertiary institutions. CONCLUSION Examining SPPH cases at various institutional levels offers a more comprehensive view of regional SPPH management and enhances targeted training in this area.
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Affiliation(s)
- Yike Yang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Clinical Research Centre for Obstetrics and Gynecology, Beijing, China
| | - Yu Shao
- Haidian Maternal and Child Health Hospital, Beijing, Beijing, China
| | - Huan Chen
- Peking University Health Science Center, Beijing, Beijing, China
| | - Xiaoyue Guo
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yingzhi Liang
- Haidian Maternal and Child Health Hospital, Beijing, Beijing, China
| | - Yan Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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Hamelin A, Pascali D, Leppard J. Just the facts: precipitous deliveries in the emergency department. CAN J EMERG MED 2023; 25:799-801. [PMID: 37436690 DOI: 10.1007/s43678-023-00552-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Alexandra Hamelin
- Department of Emergency Medicine, Clinical Epidemiology Unit, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada.
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada.
| | - Dante Pascali
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer Leppard
- Department of Emergency Medicine, Clinical Epidemiology Unit, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
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Miller S, LaLonde A. Letter to the Editor: Response to No. 431: Postpartum Hemorrhage and Hemorrhagic Shock. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:554. [PMID: 37541733 DOI: 10.1016/j.jogc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/01/2023] [Indexed: 08/06/2023]
Affiliation(s)
- Suellen Miller
- Safe Motherhood Program, School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA.
| | - Andre LaLonde
- Department of Obstetrics and Gynecology, McGill University, QC
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