Administration of fluoroquinolones emerged as the most important risk factor for CDAD in Quebec during an epidemic caused by a hypervirulent strain of C. difficile.

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T he global prevalence of obesity (body mass index [BMI], 30 kg/m 2 ) has tripled since 1975, and it is estimated that, in 2016, >1.9 billion adults were overweight (BMI, 25e29.9 kg/m 2 ), of which >650 million adults were obese. 1 Among women giving birth in the United States in 2014, 50.4% were either overweight or obese. 2 In addition, adults with a BMI of kg/m 2 comprise the most rapidly growing class of obesity in the United States. 3 Pregnant women who are classified as overweight or obese are known to be at increased risk for adverse maternal and fetal/neonatal outcomes. 4,5 However, the increased risk of pregnancy complications with each obesity class over that for women with standard BMI has not been assessed systematically. Given the high prevalence of obesity among women of childbearing age, the importance of estimating pregnancy risk with increasing BMI categories has become more pertinent than ever. ObjectiveThe objective of this study was to metaanalyze data that compares pregnancy outcomes in women with obesity and that are stratified by obesity class, with the view to counselling women and informing preventative strategies preconceptionally and during pregnancy. MethodsThis study was conducted as part of study to scrutinize the effect of obesity on mode of delivery; the study protocol

Key Clinical MessageHypercalcemia in pregnancy is an uncommon event that can cause major maternal morbidity and/or fetal or neonatal morbidity and mortality. Management is a challenge for the clinicians, especially as regards to investigations in pregnancy, surgery, and the use of cinacalcet and bisphosphonates. We present three case reports and discuss management.

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Introduction Pregnant women with a body mass index (BMI) ≥40 kg/m2 are at an increased risk of requiring planned‐ and unplanned cesarean deliveries (CD). The aim of this systematic review is to compare outcomes in women with BMI ≥ 40 kg/m2 based on planned and actual mode of birth. Material and Methods Five databases were searched for English and French‐language publications until February 2019, and all studies reporting on delivery outcomes in women with BMI ≥ 40 kg/m2, stratified by planned and actual mode of birth, were included. Risk‐of‐bias was assessed using the Newcastle‐Ottawa Scale. Relative risks (RR) and 95% confidence intervals were calculated using random‐effects meta‐analysis. Results Ten observational studies were included. Anticipated vaginal birth vs planned CD (5 studies, n = 2216) was associated with higher risk for postpartum hemorrhage (13.0% vs 4.1%, P < .001, numbers needed to harm (NNH = 11), I2 = 0%) but lower risk for wound complications (7.6% vs 14.5%, P < .001, numbers needed to treat (NNT = 15), I2 = 58.3%). Planned trial of labor vs repeat CD (3 studies, n = 4144) was associated with higher risk for uterine dehiscence (0.94% vs 0.42%, P = .04, NNH = 200, I2 = 0%), endometritis (5.1% vs 2.2%, P < .001, NNH = 35, I2 = 0%), prolonged hospitalization (one study, 30.3% vs 26.0%, P = .003, NNH = 23), low five‐minute Apgar scores (4.9% vs 1.7%, RR 2.95 (2.03, 4.28), NNH = 30, I2 = 0%) and birth trauma (1.1% vs 0.2%, P < .001, NNH = 111, I2 = 0%). Successful vaginal birth vs intrapartum CD (n = 3625) was associated with lower risk of postpartum hemorrhage (15.1% vs 70%, P < .001, NNT = 2, I2 = 0%), wound complications (one study, 0% vs 4.4%, P = .007, NNT = 23), prolonged hospitalization (one study, 1.9% vs 6.7%, 0.04, NNT = 21) and low five‐minute Apgar scores (one study, 1.0% vs 5.6%, P = .03, NNT = 22), but more birth trauma (5.9% vs 0.6%, P = .005, NNH = 19, I2 = 0%). Compared groups had dissimilar demographic characteristics. Although studies scored 6‐7/9 on risk‐of‐bias assessment, they were at high‐risk for confounding by indication. Conclusions Evidence from observational studies suggests clinical equipoise regarding the optimal mode of delivery in women with BMI ≥ 40 kg/m2 and no prior CD. This question is best answered by a randomized trial. Based on an unplanned subgroup analysis, for women with BMI ≥ 40 kg/m2 and prior CD, repeat CD may be associated with better clinical outcomes.

INTRODUCTION: To compare delivery outcomes in pregnant women with a body mass index (BMI) ≥40based on the planned and actual mode of delivery. METHODS: Five databases were searched until July 2017 to identify studies that reported on delivery outcomes in women with BMI ≥40. Outcomes were presented as proportions. Relative risks (RR) and 95% confidence intervals were calculated using random-effects meta-analysis. RESULTS: Eight observational studies with low risk-of-bias (Newcastle-Ottawa Scale) were included. Based on 1597 pregnancies, planned vaginal birth (VB) vs. planned caesarean delivery (CD) was associated with higher risk for postpartum hemorrhage (PPH) [7.27% vs. 3.44%, RR 2.116 (1.02-4.40)] and low five-minute Apgars [4.51% vs. 1.53%, RR 2.955 (1.01-8.63)]. Based on 4144 pregnancies, planned trial of scar after caesarean vs. repeat CD was associated with higher risk for endometritis [4.97% vs. 2.19%, RR 2.22 (1.60-3.09)], low five-minute Apgars [4.94% vs. 1.68%, RR 2.98 (2.03, 4.28)], birth trauma [1.06% vs. 0.21% RR 4.61 (1.77-12.03)] and prolonged hospitalization [30.3% vs. 26% RR 1.163 (1.05-1.29)]. Based on 3625 pregnancies, successful VB vs. intrapartum CD was associated with lower risk of PPH [15.06% vs 69.96%, RR 0.21 (0.19-0.23)], wound disruption [0% vs. 4.44%, RR 0.05 (0.003-0.88)], prolonged hospitalization [1.9% vs. 6.67%, RR 0.28 (0.08-0.98)] and low five-minute Apgars (0.95% vs. 5.56%, RR 0.17 (0.03-0.86)], but more birth trauma [5.91% vs. 0.56% RR 6.56 (1.26-34.10)]. Compared groups had dissimilar demographic characteristics. CONCLUSION: Given the clinical equipoise, a randomized trial is needed to determine the optimal mode of delivery in women with BMI ≥40.

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