IMPORTANCE Hemorrhage into the brain of term newborns often results in major injury and lifelong disability. The clinical epidemiology of neonatal hemorrhagic stroke (NHS) remains undefined, hindering the development of strategies to improve outcomes.OBJECTIVE To characterize the incidence, types, presentations, associated factors, and outcomes of neonatal hemorrhagic stroke. DESIGN, SETTING, AND PARTICIPANTS Population-based, nested case-control study. The Alberta Perinatal Stroke Project, a provincial registry, ascertained NHS cases using exhaustive diagnostic code searching (1992-2010, >2500 medical record reviews). Prospective cases were captured through the Calgary Pediatric Stroke Program (2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014). Participants included term neonates with magnetic resonance imaging-confirmed NHS including primary and secondary intracerebral hemorrhage, hemorrhagic transformation of ischemic injury, and presumed perinatal hemorrhagic stroke. Control infants with common data were recruited from a population-based study (4 to 1 ratio). MAIN OUTCOMES AND MEASURESInfants with NHS underwent structured medical record review using data-capture forms and blinded scoring of neuroimaging. Clinical risk factor common data elements were explored using logistic regression. Provincial live births were obtained from Statistics Canada. Outcomes were extrapolated to the Pediatric Stroke Outcome Measure. RESULTSWe identified 86 cases: 51 infants (59%) with NHS, of which 32 (67%) were idiopathic, 30 (35%) were hemorrhagic transformation of primary ischemic injuries (14 with neonatal cerebral sinovenous thrombosis, 11 with hypoxic ischemic encephalopathy, and 5 with neonatal arterial ischemic stroke), and 5 were presumed perinatal hemorrhagic stroke. Sixty-two percent were male. Incidence of pure NHS was 1 in 9500 live births and 1 in 6300 for all forms. Most presented in the first week of life with seizures and encephalopathy. Acute neurosurgical intervention was rare (3 of 86 total cases; 3.5%). Temporal lobe was the most common NHS location (16 of 51 pure NHS cases; 31%). A primary cause was evident in 19 of the 51 cases of non-hemorrhagic transformation NHS (37%). Idiopathic NHS was independently associated with lower maternal age (odds ratio [OR], 0.87; 95% CI, 0.78-0.94), primiparity (OR, 2.98; 95% CI, 1.18-7.50), prior spontaneous abortion (OR, 0.11; 95% CI, 0.02-0.53), difficult fetal transition (bradycardia [OR, 15.0; 95% CI,] and low Apgar [OR, 14.3; 95% CI, 2.77-73.5]), and small for gestational age (OR, 14.3; 95% CI, 1.62-126.1). Follow-up of 50 cases at a median of 37 months demonstrated poor neurological outcomes in 21 patients (44%). CONCLUSIONS AND RELEVANCENeonatal hemorrhagic stroke is more common than previously reported, occurring in at least 1 in 6300 live births. Etiologies are approximately equally distributed between idiopathic, secondary, and hemorrhagic transformation. Clinical associations do not suggest a common mechanism or predictability of NHS. Recurrence is rare. Outcomes a...

Women who participated in the Community Perinatal Care study (CPC), a trial of increasing support during pregnancy, were contacted by telephone and asked to participate in a follow-up study when their child was three years of age. As part of the trial, women completed three telephone questionnaires, conducted at 1) study intake, 2) 32-36 weeks gestation, and 3) eight weeks postpartum. Comprehensive demographic, obstetric, lifestyle, mental health, psychosocial, parenting and resource use information was obtained, and was used for risk factor assessment in the current study. The methodology of the CPC study has been described in detail elsewhere 29 and adhered to the CONSORT statement. The trial inter

Background:A link exists between breastfeeding difficulties and postpartum depression, and evidence shows that some breastfeeding promotion initiatives may increase maternal stress and contribute to risk of the condition. We conducted a prospective cohort study to determine whether breastfeeding difficulties affect the risk of postpartum depression and whether breastfeeding support modifies the relationship between breastfeeding difficulties and postpartum depression. Methods:Between June and October 2010, we recruited 442 women who intended to breastfeed from all maternity hospitals in Calgary within 72 hours of giving birth to full-term, singleton infants. We administered questionnaires at birth and 6 weeks and 6 months postpartum, measuring breastfeeding difficulties, exposure to breastfeeding supports and postpartum depression. We used qualitative inquiry to measure breastfeeding support experiences. Postpartum depression was defined as a score of 10 or greater on the Edinburgh Postnatal Depression Scale or a self-reported diagnosis of depression in the first 6 months postpartum.Results: A total of 386 women (87.3%) reported moderate to severe breastfeeding difficulties and 437 (98.9%) received some form of breastfeeding advice, help or support. Among women with breastfeeding difficulties, those who did not report a negative breastfeeding support experience were at decreased risk of postpartum depression (risk ratio 0.36). In the final regression model a negative breastfeeding support experience was a significant effect modifier of the relationship between breastfeeding difficulties and postpartum depression.Interpretation: The quality of breastfeeding support is important not only for breastfeeding promotion but also for maternal mental health. Educating front-line caregivers to ensure that support experiences of breastfeeding women are positive can reduce the risk of postpartum depression. Abstract Research CMAJ OPEN E104CMAJ OPEN, 4(1)

BackgroundPostpartum depression (PPD) is a common complication of pregnancy, affecting approximately 13% of mothers internationally. Previous research has examined whether epidural analgesia used for pain control during labor and birth is associated with a lower risk of PPD, but reports conflicting results and may have suffered from methodological shortcomings. Our study aimed to prospectively assess whether epidural analgesia is associated with a lower risk of PPD (at either 6 weeks or 6 months postpartum) after attempting to adequately adjust for selection bias and confounding variables.MethodsWe conducted a secondary analysis of a prospective cohort of urban Canadian mothers who were recruited at birth in Calgary, Canada, in 2010, for a primary study on predictors of PPD. Mothers with full-term, singleton infants who did not require neonatal intensive care unit admission of >24 hours were included, and filled out questionnaires at birth, 6 weeks and 6 months postpartum including demographics, birth data, maternal and infant physical health, lifestyle, breastfeeding and maternal mental health. Descriptive statistics were calculated for participant characteristics and to identify potential confounder variables. Multivariable logistic regression analysis was conducted to assess whether epidural analgesia is associated with PPD after controlling for available confounding variables.ResultsOur study included 206 mothers who had vaginal deliveries and were free of depression at delivery. We found an incidence of PPD of 13.3% (n=27) and no statistically significant association between epidural use and PPD, regardless of adjustment for potential confounding variables (unadjusted odds ratio [OR] 0.86, 95% confidence interval [CI] 0.69–1.22; adjusted OR (for body mass index 1.04, 95% CI 0.40–2.77).ConclusionWe did not observe a significant association between epidural use and PPD. While the CIs are wide, we do not believe that this masks a clinically relevant association, and as such, the risks and benefits of epidural analgesia communicated to women during labor and delivery should not be modified.

Obesity in pregnancy increases the risk of delivery of a macrosomic infant in both primiparous and multiparous women. The maternal, fetal and neonatal outcomes of macrosomic pregnancies are similar in obese and normal weight women.

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Angiogenesis is essential for normal lung development. The objective of our study was to test the hypothesis that preeclampsia, an antiangiogenic state, is a risk factor for bronchopulmonary dysplasia (BPD). Prospective cohort study of infants less than 32 weeks' gestation born to mothers with preeclampsia between January 2007 and June 2010 at a single tertiary care center. Their BPD outcome was compared with infants born to the next two normotensive mothers with a ± 1 week gestational age difference. BPD was defined as oxygen dependency at 36 weeks' postmenstrual age. Multivariable binary regression was used to estimate the risk ratio (RR) of BPD with preeclampsia exposure and adjust for confounders. Of 102 infants in the preeclampsia group, 23 (23%) developed BPD and of the 217 infants in the normotensive group, 56 (26%) developed BPD. On multivariable binary regression modeling, preeclampsia was not a risk factor for development of BPD (RR: 0.5, 95% confidence interval [CI]: 0.20-1.20). Surfactant use, Score for Neonatal Acute Physiology Perinatal Extension-II score, sepsis, blood transfusion, and intrauterine growth restriction (IUGR) were significant risk factors for BPD. In our cohort, preeclampsia was not a significant risk factor for BPD. IUGR infants of preeclamptic and normotensive mothers were at higher risk for BPD.

Background: Urinary incontinence affects up to half of women, yet few speak to their health care provider about or receive treatment for the condition. To aid with identifying subpopulations at risk for urinary incontinence, we examined the associations between 10 chronic health conditions and urinary incontinence among Canadian adult females. Methods: We conducted a cross-sectional analysis of survey data from the Canadian Community Health Survey (2013–2014) involving female respondents aged 25 years or older living in a private dwelling. Presence of chronic conditions and urinary incontinence were measured by self-report. We used logistic regression modelling with sampling weights, controlling for age, income, ethnicity, body mass index and smoking. Multiple imputation and probabilistic bias analysis were used to address missing covariate data and unmeasured confounding from parity. Results: Our analysis included 60 186 respondents representing more than 12 million Canadian females, of whom 45.8% (95% confidence interval [CI] 45.0%–46.6%) reported at least 1 chronic condition. Chronic conditions were associated with more than twice the odds of urinary incontinence (adjusted odds ratio [OR] 2.42, 95% CI 2.02–2.89). Associations were largest for bowel disorders (adjusted OR 2.92, 95% CI 2.44–3.49); modest for chronic obstructive pulmonary disease (adjusted OR 2.00, 95% CI 1.63–2.45), asthma (adjusted OR 1.82, 95% CI 1.52–2.19), arthritis (adjusted OR 1.98, 95% CI 1.74–2.24) and heart disease (adjusted OR 1.73, 95% CI 1.48–2.02); and smallest for diabetes (adjusted OR 1.20, 95% CI 1.02–1.41) and high blood pressure (adjusted OR 1.27, 95% CI 1.12–1.44). Results slightly attenuated but did not substantively change after imputation and bias analysis. Interpretation: We found that chronic conditions are associated with significantly higher odds of comorbid urinary incontinence among Canadian adult females, which is consistent with previous research. Our findings support routine inquiry regarding urinary incontinence symptoms among women accessing health care for chronic conditions.