Showing papers in "Acta Obstetricia et Gynecologica Scandinavica in 2011"
TL;DR: Placental abruption, classically defined as a premature separation of the placenta before delivery, is one of the leading causes of vaginal bleeding in the second half of pregnancy.
Abstract: Placental abruption, classically defined as a premature separation of the placenta before delivery, is one of the leading causes of vaginal bleeding in the second half of pregnancy. Approximately 0.4-1% of pregnancies are complicated by placental abruption. The prevalence is lower in the Nordic countries (0.38-0.51%) compared with the USA (0.6-1.0%). Placental abruption is also one of the most important causes of maternal morbidity and perinatal mortality. Maternal risks include obstetric hemorrhage, need for blood transfusions, emergency hysterectomy, disseminated intravascular coagulopathy and renal failure. Maternal death is rare but seven times higher than the overall maternal mortality rate. Perinatal consequences include low birthweight, preterm delivery, asphyxia, stillbirth and perinatal death. In developed countries, approximately 10% of all preterm births and 10-20% of all perinatal deaths are caused by placental abruption. In many countries, the rate of placental abruption has been increasing. Although several risk factors are known, the etiopathogenesis of placental abruption is multifactorial and not well understood.
258 citations
TL;DR: Proper and timely diagnosis of PPH should above all include accurate estimation of blood loss before vital signs change, andimation ofBlood loss by calibrated bags has been shown to be significantly more accurate than visual estimation at vaginal delivery.
Abstract: Maternal mortality due to postpartum hemorrhage (PPH) continues to be one of the most important causes of maternal death worldwide. PPH is a significantly underestimated obstetric problem, primarily because a lack of definition and diagnosis. The 'traditional' definition of primary PPH based on quantification of blood loss has several limitations. Notoriously, blood loss is not measured or is significantly underestimated by visual estimation and there are no generally accepted cut-offs limits for estimated blood loss. A definition based on hematocrit change is not clinically useful in an emergency such as PPH, as a fall in hematocrit postpartum shows poor correlation with acute blood loss. The need for erythrocyte transfusion alone to define PPH is also of limited value, as the practice of blood transfusion varies widely. Definitions based on symptoms of hemodynamic instability are problematic, as they are late signs of depleted blood volume and commencing failure of compensatory mechanisms threatening the mother's life. There is thus currently no single, satisfactory definition of primary PPH. Proper and timely diagnosis of PPH should above all include accurate estimation of blood loss before vital signs change. Estimation of blood loss by calibrated bags has been shown to be significantly more accurate than visual estimation at vaginal delivery. Careful monitoring of the mother's vital signs, laboratory tests, in particular coagulation testing, and immediate diagnosis of the cause of PPH are important key factors to reduce maternal morbidity and mortality.
177 citations
TL;DR: Antenatal diagnosis of placenta accreta may reduce peripartum blood loss and the need for blood transfusion and women with antenatal diagnosis more often haveplacenta previa and history of previous cesarean section, and the clinical diagnosis is more often placente percreta.
Abstract: Objective. Placenta accreta is one of the most devastating pregnancy complications. We sought to compare outcomes between women with placenta accreta when diagnosed antenatally or intrapartum, and to define predictors of the antenatal diagnosis. Design. Retrospective case–control study. Setting. University teaching hospital. Population. Twenty-four women with placenta accreta diagnosed antenatally and 20 women discovered intrapartum. Methods. Chart review of historical and delivery-associated variables. Rates were compared between the groups. Main Outcome Measures. Placenta accreta diagnosed antenatally or intrapartum. Results. Women with antenatal diagnosis had a lower estimated blood loss of a median of 4500ml (range 100–15000ml) compared with 7800ml (range 2500–17000ml, p=0.012) and required fewer units of packed red blood cells transfused (median 7; range 0–27 compared with 13.5; range 4–31, p=0.026). Nineteen (79%) women diagnosed antenatally had balloon catheter occlusion carried out during the cesarean section. Five (21%) had the entire placenta left in situ. There was no difference in the rate of surgical complications or duration of hospitalization. The clinical diagnosis among women with antenatal diagnosis was more often placenta percreta (p=0.013). The risk factor profile of women with antenatal diagnosis of placenta accreta included higher gravidity (p=0.014) and parity (p<0.0001), history of cesarean section (p=0.004), and placenta previa in the current pregnancy (p<0.001). Conclusions. Antenatal diagnosis of placenta accreta may reduce peripartum blood loss and the need for blood transfusion. Women with antenatal diagnosis more often have placenta previa and history of previous cesarean section, and the clinical diagnosis is more often placenta percreta.
153 citations
TL;DR: It is determined that singletons born to women with low total gestational weight gain have higher risks of preterm birth and low birthweight, with the lower the gain, the higher the risks.
Abstract: BACKGROUND: Low gestational weight gain is common, with potential adverse perinatal outcomes. OBJECTIVE: To determine the relation between low gestational weight gain and preterm birth and low birthweight in singletons in developing and developed countries. DATA SOURCES: Medline, EMBASE and reference lists were searched, identifying 6,283 titles and abstracts. METHODS OF STUDY SELECTION: Following the MOOSE consensus statement, two assessors independently reviewed titles, abstracts, full articles, extracted data and assessed quality. RESULTS: Fifty-five studies, 37 cohort and 18 case-control, were included, involving 3,467,638 women. In the cohort studies (crude data, generally supported where available by adjusted data and case-control studies), women with low total gestational weight gain had increases in preterm birth <37 weeks [RR 1.64 (95%CI 1.62-1.65)], 32-36 weeks [RR 1.39 (95%CI 1.38-1.40)] and ≤ 32 weeks [RR 3.80 (95%CI 3.72-3.88)]. Low total gestational weight gain was associated with increased risks of low birthweight <2,500 g [RR 1.85 (95%CI 1.72-2.00)], in developing and developed countries [RR 1.84 (95%CI 1.71-1.99) and RR 3.02 (95%CI 1.37-6.63), respectively], 1,500-2,500 g [RR 2.02 (95%CI 1.88-2.17)] and <1,500 g (RR 2.00 (95%CI 1.67-2.40)]. Women with low weekly gestational weight gain were at increased risk of preterm birth [RR 1.56 (95%CI 1.26-1.94)], 32-36 weeks [RR 2.43 (95%CI 2.37-2.50)] and ≤ 32 weeks [RR 2.31 (95%CI 2.20-2.42)] but not low birthweight [RR 1.64 (95%CI 0.89-3.02)]. CONCLUSIONS: In this systematic review, we determined that singletons born to women with low total gestational weight gain have higher risks of preterm birth and low birthweight, with the lower the gain, the higher the risks.
149 citations
TL;DR: The evidence for three theories of how preconceptional psychosocial stress could act as a contributing determinant of excess preterm birth risk among African American women are reviewed, with mixed evidence leans towards modest associations.
Abstract: Objective We reviewed the evidence for three theories of how preconceptional psychosocial stress could act as a contributing determinant of excess preterm birth risk among African American women: early life developmental plasticity and epigenetic programming of adult neuroendocrine systems; blunting, weathering, or dysfunction of neuroendocrine and immune function in response to chronic stress activation through the life course; individuals' adoption of risky behaviors such as smoking as a response to stressful stimuli Methods Basic science, clinical, and epidemiologic studies indexed in MEDLINE and Web of Science databases on preconceptional psychosocial stress, preterm birth and race were reviewed Results Mixed evidence leans towards modest associations between preconceptional chronic stress and preterm birth (for example common odds ratios of 12-14), particularly in African American women, but it is unclear whether this association is causal or explains a substantial portion of the Black-White racial disparity in preterm birth The stress-preterm birth association may be mediated by hypothalamic-pituitary-adrenal axis dysfunction and susceptibility to bacterial vaginosis, although these mechanisms are incompletely understood Evidence for the role of epigenetic or early life programming as a determinant of racial disparities in preterm birth risk is more circumstantial Conclusions Preconceptional stress, directly or in interaction with host genetic susceptibility or infection, remains an important hypothesized risk factor for understanding and reducing racial disparities in preterm birth Future studies that integrate adequately sized epidemiologic samples with measures of stress, infection, and gene expression, will advance our knowledge and allow development of targeted interventions
129 citations
TL;DR: Reduction in the rate of vaginal delivery was correlated with a significant reduction in rates of intrapartum or early neonatal mortality and morbidity, but at a much lower level than reported in the Term Breech Trial.
Abstract: Objective. To analyze the consequences of the handling of breech presentation in Denmark after publication of the Term Breech Trial (TBT). Design. Population-based retrospective cohort study. Settings. Data from the National Birth Registry and discharge letters from cases with perinatal death. Population. Singleton breech fetuses at term and alive at onset of labor delivered between 1997 and 2008 (n=23 789). Methods. Outcomes before and after publication of TBT were compared and analyzed by planned mode of delivery. Main outcome measures. Cesarean section, intrapartum or early neonatal mortality in infants without lethal congenital malformations, Apgar score ≤6 at five minutes and admittance to neonatal intensive care unit (NICU) for four days or more. Results. The rate of cesarean section increased from 79.6 to 94.2%. Intrapartum or early neonatal mortality was reduced from 0.13 to 0.05%[relative risk (RR) 0.38 (95% confidence intervals (CI) 0.15–0.98)]. The incidence of low Apgar scores declined from 1.0 to 0.6%[RR 0.83 (95%CI 0.73–0.95)] and admission to NICU from 4.2 to 3.2%[RR 0.92 (95%CI 0.87–0.97)]. Planned vaginal delivery was associated with an increased risk of mortality, low Apgar score and admission to NICU throughout the period. Conclusion. Reduction in the rate of vaginal delivery was correlated with a significant reduction in rates of intrapartum or early neonatal mortality and morbidity, but at a much lower level than reported in the Term Breech Trial. The lower rate of vaginal delivery, indicating a strict selection of women, did not reduce the relative risks of complications during a planned vaginal delivery.
106 citations
TL;DR: Measurement of uterine electromyography (EMG) has been shown to detect contractions as accurately as the currently used methods and can help to identify patients in true labor better than any other method presently employed in the clinic.
Abstract: Current methodologies to assess the process of labor, such as tocodynamometry or intrauterine pressure catheters, fetal fibronectin, cervical length measurement and digital cervical examination, have several major drawbacks. They only measure the onset of labor indirectly and do not detect cellular changes characteristic of true labor. Consequently, their predictive values for term or preterm delivery are poor. Uterine contractions are a result of the electrical activity within the myometrium. Measurement of uterine electromyography (EMG) has been shown to detect contractions as accurately as the currently used methods. In addition, changes in cell excitability and coupling required for effective contractions that lead to delivery are reflected in changes of several EMG parameters. Use of uterine EMG can help to identify patients in true labor better than any other method presently employed in the clinic.
98 citations
TL;DR: Currently available published studies on gynecological cancer surveillance in women with HNPCC do not adequately allow for evidence‐based clinical decisions, and detection of endometrial cancer or hyperplasia in nonsymptomatic women belonging to an H NPCC family is improved by adding routine endometrian sampling along with transvaginal ultrasound for surveillance visits.
Abstract: Objective/design We performed a systematic review of studies that evaluate the role of gynecological cancer surveillance in women who carry a hereditary nonpolyposis colorectal cancer (HNPCC) mutation or belong to a family that fulfills the criteria for HNPCC. Methods The PubMed database and a clinical trials database were used to identify relevant studies. We included studies that reported results of gynecological cancer surveillance in women who carry a HNPCC mutation, belong to a family in which a HNPCC mutation was detected or belong to a family fulfilling the Amsterdam II criteria. Main outcome measures Number and stage of cancers, interval cancers and cancer precursor states detected at screening. Results Five studies fulfilled our review criteria. Surveillance modalities for endometrial cancer included transvaginal ultrasound combined with endometrial sampling when indicated, or transvaginal ultrasound with a routine endometrial biopsy, and, in certain studies, the tumor marker CA-125. The highest yield of pathological findings in surveillance visits, from 5 to 6.5%, occurred in studies that included routine endometrial biopsies. Without a routine sampling, 7/14 cancers and 11/18 hyperplasias would have been missed. One case of advanced ovarian cancer was detected at surveillance. Conclusions Currently available published studies on gynecological cancer surveillance in women with HNPCC do not adequately allow for evidence-based clinical decisions. Detection of endometrial cancer or hyperplasia in nonsymptomatic women belonging to an HNPCC family is improved by adding routine endometrial sampling along with transvaginal ultrasound for surveillance visits. No benefit was shown for ovarian cancer surveillance.
94 citations
TL;DR: An overview of current research on risk factors for cerebral palsy (CP) in children born at term is provided and how new findings can affect the content of the CP registers worldwide is hypothesized.
Abstract: Objective To provide an overview of current research on risk factors for cerebral palsy (CP) in children born at term and hypothesize how new findings can affect the content of the CP registers worldwide. Design A systematic search in PubMed for original articles, published from 2000 to 2010, regarding risk factors for CP in children born at term was conducted. Methods Full text review was made of 266 articles. Main outcome measures Factors from the prenatal, perinatal and neonatal period considered as possible contributors to the causal pathway to CP in children born at term were regarded as risk factors. Results Sixty-two articles met the criteria for an original report on risk factors for CP in children born at term. Perinatal adverse events, including stroke, were the focus of most publications, followed by genetic studies. Malformations, infections, perinatal adverse events and multiple gestation were risk factors associated with CP. The evidence regarding, for example, thrombophilic factors and non-CNS abnormalities was inconsistent. Conclusions Information on maternal and neonatal infections, umbilical cord blood gases at birth, mode of delivery and placental status should be collected in a standardized way in CP registers. Information on social factors, such as education level, family income and area of residence, is also of importance. More research is needed to understand the risk factors of CP and specifically how they relate to causal pathways of cerebral palsy.
92 citations
RTI International1, Aga Khan University2, University of Zambia3, University of Buenos Aires4, Moi University5, Government Medical College, Nagpur6, National Institutes of Health7, Christiana Care Health System8, University of Alabama at Birmingham9, Anschutz Medical Campus10, Tulane University11, Indiana University – Purdue University Indianapolis12, University of North Carolina at Chapel Hill13, University of Cincinnati14, Drexel University15
TL;DR: In these low‐middle income countries, most stillbirth offspring were not macerated, were reported as ≥37 weeks’ gestation, and almost half weighed at least 2 500g, suggesting many of these stillbirths could likely be prevented.
Abstract: OBJECTIVE: To determine population-based stillbirth rates and to determine whether the timing and maturity of the stillbirths suggest a high proportion of potentially preventable deaths. DESIGN: Prospective observational study. SETTING: Communities in six low-income countries (Democratic Republic of Congo Kenya Zambia Guatemala India and Pakistan) and one site in a mid-income country (Argentina). POPULATION: Pregnant women residing in the study communities. METHODS: Over a five-year period in selected catchment areas using multiple methodologies trained study staff obtained pregnancy outcomes on each delivery in their area. MAIN OUTCOME MEASURES: Pregnancy outcome stillbirth characteristics. RESULTS: Outcomes of 195400 deliveries were included. Stillbirth rates ranged from 32 per 1000 in Pakistan to 8 per 1000 births in Argentina. Three-fourths (76%) of stillbirth offspring were not macerated 63% were >/= 37 weeks and 48% weighed 2500 g or more. Across all sites women with no education of high and low parity of older age and without access to antenatal care were at significantly greater risk for stillbirth (p /= 37 weeks gestation and almost half weighed at least 2500 g. With access to better medical care especially in the intrapartum period many of these stillbirths could likely be prevented. (c) 2011 Nordic Federation of Societies of Obstetrics and Gynecology No claim to original US government works.
88 citations
TL;DR: Marine n‐3 fatty acids administered in pregnancy reduce the rate of preterm birth and increase birthweight and a systematic review of randomized controlled trials of relevance found no differences between the intervention and the control groups.
Abstract: BACKGROUND: Preterm delivery remains a substantial healthcare problem, complicating 5-10% of pregnancies, and is the major cause of perinatal morbidity and mortality in the developed world. Few effective methods to prevent preterm delivery have been identified to date. OBJECTIVE: To review systematically the evidence from randomized controlled trials with respect to the hypothesis that increased consumption of marine n-3 fatty acids in pregnancy can prevent preterm birth. SETTING: Electronic searches of the following databases were performed: PubMed (1995-2009), SCOPUS including EMBASE (1995-2009), and Cochrane Library. A combination of key words and text words related to fish oil, marine n-3 fatty acids, fish consumption, preterm birth, preterm delivery, prematurity, pregnancy duration, gestational age, parturition, delivery and pregnancy were used. METHODS: A systematic review of randomized controlled trials of relevance was conducted. Three trials were included, comprising 921 women for whom data on gestational age and 1 187 women for whom data on birthweight were available. RESULTS: Overall, 46 (8.9%) of 516 women who received n-3 fatty acids gave birth before 37 completed weeks of gestation, compared with 66 (16.3%) of 405 in the control group [relative risk 0.61; 95% confidence interval (CI) 0.40-0.93; p<0.05]. Data on delivery before 34 completed weeks showed the same trend (relative risk 0.32; 95% CI 0.09-0.95). Overall, the mean birthweight was 71g higher in women who received n-3 fatty acids during pregnancy (95% CI 4.73-138.12; p<0.05). The rate of low birthweight was not statistically significantly different between the intervention and the control groups. The mean gestational age at delivery was significantly higher by 4.5 days in the intervention group supplemented with n-3 fatty acids compared with placebo (95% CI 2.3-6.8; p<0.05). CONCLUSIONS: Marine n-3 fatty acids administered in pregnancy reduce the rate of preterm birth and increase birthweight.
TL;DR: Severe postpartum hemorrhage may have a long‐term psychological impact on women despite uterine preservation, and 15 women who had a subsequent full‐term pregnancy reported intense anxiety throughout the pregnancy, and one developed depression requiring antidepressant treatment during pregnancy.
Abstract: Objective. To estimate the long-term psychological impact of severe postpartum hemorrhage in women whose uterus was preserved. Design. Retrospective study. Setting. University-affiliated tertiary referral center. Population. All consecutive women who underwent embolization for postpartum hemorrhage between 1994 and 2007 and whose uterus was preserved were included. Methods. Data were retrieved from medical files and semi-structured telephone interviews. In semi-structured interviews, women were asked about their perceptions and memories of the experience. Main Outcome Measures. Perceptions and memories of the postpartum hemorrhage during and after delivery. Results. Follow-up was successful for 68 of the 91 (74.7%) women included. Of the 46 (67.6%) who reported negative memories of the delivery and postpartum period, the main memory for 24 was a fear of dying (35.3%). Of the 28 (41.2%) who reported continued repercussions, 16 (23.5%) thought about this delivery and its complications at least once a month, five (7.3%) reported persistent fear of dying, four (5.9%) reported sexual problems, and three (4.4%) women considered that the event was, at least in part, responsible for their subsequent divorce. Of the 15 women who had a subsequent full-term pregnancy, nine (60%) reported intense anxiety throughout the pregnancy, and one (6.7%) developed depression requiring antidepressant treatment during pregnancy. Conclusions. Severe postpartum hemorrhage may have a long-term psychological impact on women despite uterine preservation.
TL;DR: A marked decrease in multiple births was the main reason for better pregnancy and neonatal outcome and may also have a beneficial effect on long‐term results, notably cerebral palsy.
Abstract: Objective. To summarize data on deliveries after IVF performed in Sweden up to 2006. Design. Cohort study of women and children, conceived after IVF with comparisons of deliveries after IVF before and after April 1, 2001. Setting. Study based on Swedish health registers. Population. Births registered in the Swedish Medical Birth Register with information on IVF from all IVF clinics in Sweden. Methods. Results from the second study period are summarized and outcomes between the two periods are compared. Long term follow-up is based on data from both periods. Main outcome measures. Maternal and perinatal outcomes, long term sequels. Results. Some maternal pregnancy complications decreased in rate, notably preeclampsia and PROM. The rate of multiple births and preterm births decreased dramatically with a better neonatal outcome, including neonatal mortality. No difference in outcome existed between IVF and ICSI or between the use of fresh and cryopreserved embryos, but children born after blastocyst transfer had a slightly higher risk for preterm birth and congenital malformations than children born after cleavage stage transfer. An increased risk for cerebral palsy, possibly for attention deficit and hyperactivity disorder, for impaired visual acuity, and for childhood cancer was noted but these outcomes were rare also after IVF. An increased risk for asthma was demonstrated. No effect on maternal cancer risk was seen. Conclusions. A marked decrease in multiple births was the main reason for better pregnancy and neonatal outcome and may also have a beneficial effect on long-term results, notably cerebral palsy. (Less)
TL;DR: Fetal malpresentation, including persistent occipitoposterior position, is a major cause of dystocia resulting in obstetric interventions and frequently leads to cesarean section or instrumental delivery, especially among primiparous women.
Abstract: Fetal malpresentation, including persistent occipitoposterior position, is a major cause of dystocia resulting in obstetric interventions. We studied malpresentation among 11 957 consecutive singleton deliveries from 1995 to 2004. There were 1 030 deliveries with a malpresentation (8.6%). Cephalic malpresentations occurred in 5.4% of deliveries (persistent occipitoposterior 5.2%, face 0.1%, brow 0.14%), and 3.1% had breech presentation and 0.12% a transverse lie. The odds ratios (OR) for cesarean section were 14.89 (95%CI 11.91-18.63) in breech presentation and 4.57 (95% CI 3.85-5.42) in persistent occipitoposterior presentation. With persistent occipitoposterior position, the OR for instrumental vaginal delivery was 3.84 (95%CI 3.14-4.70). Primiparity was associated with increased malpresentation risks, as 54.6% of those with malpresentations were primiparous compared with 41.7% of those without (OR 1.68, 95%CI 1.48-1.91, p < 0.001). Primiparous women required more cesarean sections (OR 1.92, 95%CI 1.50-2.47) and instrumental deliveries (OR 2.89, 95%CI 1.50-2.47). Malpresentation frequently leads to cesarean section or instrumental delivery, especially among primiparous women.
TL;DR: To enhance women's access to postabortion care, focus is increasingly being placed on upgrading midlevel providers to provide emergency treatment as well as implementing misoprostol as a treatment strategy for complications after unsafe abortion.
Abstract: Forty per cent of the world's women are living in countries with restrictive abortion laws, which prohibit abortion or only allow abortion to protect a woman's life or her physical or mental health. In countries where abortion is restricted, women have to resort to clandestine interventions to have an unwanted pregnancy terminated. As a consequence, high rates of unsafe abortion are seen, such as in Sub-Saharan Africa where unsafe abortion occurs at rates of 18–39 per 1 000 women. The circumstances under which women obtain unsafe abortion vary and depend on traditional methods known and types of providers present. Health professionals are prone to use instrumental procedures to induce the abortion, whereas traditional providers often make a brew of herbs to be drunk in one or more doses. In countries with restrictive abortion laws, high rates of maternal death must be expected, and globally an estimated 66 500 women die every year as a result of unsafe abortions. In addition, a far larger number of women experience short- and long-term health consequences. To address the harmful health consequences of unsafe abortion, a postabortion care model has been developed and implemented with success in many countries where women do not have legal access to abortion. Postabortion care focuses on treatment of incomplete abortion and provision of postabortion contraceptive services. To enhance women's access to postabortion care, focus is increasingly being placed on upgrading midlevel providers to provide emergency treatment as well as implementing misoprostol as a treatment strategy for complications after unsafe abortion.
TL;DR: It is argued that infection may not be a cause of racial disparity but in association with other risk factors such as stress, nutritional deficiency, and differences in genetic variations in PTB, pathways and their complex interactions may produce differential inflammatory responses that may contribute to racial disparity.
Abstract: Infection has been hypothesized to be one of the factors associated with spontaneous preterm birth (PTB) and with the racial disparity in rates of PTB between African American and Caucasian women. However, recent findings refute the generalizability of the role of infection and inflammation. African Americans have an increased incidence of PTB in the setting of intraamniotic infection, periodontal disease, and bacterial vaginosis compared to Caucasians. Herein we report variability in infection- and inflammation-related factors based on race/ethnicity. For African American women, an imbalance in the host proinflammatory response seems to contribute to infection-associated PTB, as evidenced by a greater presence of inflammatory mediators with limited or reduced presence of immune balancing factors. This may be attributed to differences in the genetic variants associated with PTB between African Americans and Caucasians. We argue that infection may not be a cause of racial disparity but in association with other risk factors such as stress, nutritional deficiency, and differences in genetic variations in PTB, pathways and their complex interactions may produce differential inflammatory responses that may contribute to racial disparity.
TL;DR: Anal incontinence was more frequent in patients diagnosed with than without ultrasound‐identified anal sphincter muscle defects at 10 months postpartum follow‐up, and prenatal obstetric and maternal variables could not predict anal incontinent.
Abstract: Objective. To study prevalence and risk factors for anal incontinence (AI) after obstetric anal sphincter rupture. Material and methods. This was a retrospective clinical observational study. Among 14 959 vaginal deliveries, 591 women were diagnosed with obstetric anal sphincter ruptures (3.9%) at one Norwegian University Hospital in 2003–2005. Patients were examined and interviewed approximately 10 months after delivery. Anal continence was classified with St. Mark's incontinence score (0, complete anal continence; ≥3, anal incontinence), and defects in anal sphincter muscles were diagnosed by endoanal ultrasound. Prevalence of anal incontinence was assessed in relation to obstetrical and maternal characteristics as well as the correlation between anal incontinence and ultrasound-detectable defects of sphincter muscle. Results. Anal incontinence with a St. Mark's score of ≥3 was reported by 21% of women with obstetric anal sphincter rupture, with inability to control gas as the most prevalent symptom. Women with AI were more likely to report urinary incontinence compared with women having no AI. In a multiple regression analysis of maternal and obstetrical risk factors, fourth degree sphincter tear was the only significant risk factor for AI. Anal incontinence was more frequent in patients diagnosed with than without ultrasound-identified anal sphincter muscle defects at 10 months postpartum follow-up. Conclusion. Anal as well as urinary incontinence after delivery with obstetric anal sphincter rupture is common, and prenatal obstetric and maternal variables could not predict anal incontinence. Fourth degree perineal tear and a persistent ultrasound-detected defect in the anal sphincter muscles are associated with AI.
TL;DR: Most surgical hemostatic failures that led to hysterectomy occurred in women with severe hemodynamic deterioration and coagulopathy, and strong association between topographical uterine irrigation areas and surgical he mostatic technique was established.
Abstract: Objective To analyze the efficacy of surgical techniques to stop excessive obstetric bleeding. Design Retrospective follow up. Setting Center for Medical Education and Clinical Research and a total of twelve hospitals in Buenos Aires. Population Five hundred and thirty-nine consecutive patients were included: 361 had placenta accreta-percreta, 114 uterine atony, 19 cervical scar pregnancy, 21 placenta previa and 24 uterine-cervical-vaginal tears. Three hundred and forty-seven women had surgery, of whom 192 were emergencies. Methods The surgical techniques included selective arterial ligation and compression procedures. The effectiveness of the techniques was assessed by cessation of bleeding according to source. Follow up included hysteroscopy of 100 patients and magnetic resonance imaging of 341 patients. Main outcome measures Strong association between topographical uterine irrigation areas and surgical hemostatic technique was established. Results Hemorrhage stopped following arterial ligation or compression sutures in 499 women, but hysterectomy was needed in 40. In cervical, lower segment and upper vaginal bleeding, Cho's compression sutures proved to be an efficient and simple procedure. Most surgical hemostatic failures that led to hysterectomy occurred in women with severe hemodynamic deterioration and coagulopathy. Two women died due to multiorgan failure. After surgery, 116 successful pregnancies were reported. Conclusions Bilateral occlusions of the uterine artery or its branches were useful procedures to stop upper uterine bleeding. Square sutures were a simple and effective procedure to control lower genital tract bleeding.
TL;DR: These results show that GDM is associated with elevated IL‐6 levels independent of obesity levels, both during pregnancy and after delivery.
Abstract: Objective. Recent studies have shown that high interleukin-6 (IL-6) secretion may aggravate insulin resistance in pregnancy and participate in the pathogenesis of gestational diabetes mellitus (GDM). The aim of this study was to determine whether the presence of GDM is associated with elevated IL-6 concentrations and whether this association remains after delivery, independent of body mass index. Design. Longitudinal study. Setting. Hospital-based. Sample. Forty-seven women were screened for GDM with a 75g oral glucose tolerance test at 26.1±3.7 weeks of pregnancy following the Canadian Diabetes Association guidelines (20 GDM, 27 control subjects). Main outcome measures. Interleukin-6 levels were measured by ELISA at the time of GDM screening and two months post-partum. Results. Interleukin-6 concentrations were significantly higher in women with GDM compared with control women at the time of GDM screening (1.47±0.72 vs. 0.90±0.32pg/mL, p≤0.01). Similar results were obtained two months post-partum, where IL-6 levels remained significantly higher in women with GDM compared with control women (1.88±0.85 vs. 1.41±0.87pg/mL, p≤0.05). Interleukin-6 concentrations were significantly correlated with the Matsuda insulin sensitivity index, measured at the two time points (r=–0.60, p≤0.01 and r=–0.34, p≤0.05). The Matsuda insulin sensitivity index was an independent and significant predictor of IL-6 concentrations at the time of GDM screening, explaining 35.6% of the variance (p≤0.0001) in this variable. IL-6 concentration measured at GDM screening was identified as an independent and significant predictor of post-partum IL-6 concentrations, explaining 28.6% of the variance (p≤0.001). Conclusions. These results show that GDM is associated with elevated IL-6 levels independent of obesity levels, both during pregnancy and after delivery.
TL;DR: The high prevalences of zinc and vitamin B‐12 deficiencies in early pregnancy are a concern, as it could lead to adverse pregnancy outcomes and increased health risks for both mother and child.
Abstract: OBJECTIVE: To describe the prevalence of anemia and micronutrient deficiencies as well as their determinants in early pregnancy. DESIGN: Baseline data from a population-based randomized intervention trial. SETTING: The study was conducted in Matlab a sub-district in rural Bangladesh from 1 January to 31 December 2002. POPULATION: Pregnant women (n= 740) were enrolled in approximately week 14 in pregnancy. METHODS: Data were collected using questionnaires physical examinations and laboratory analyses of blood samples for concentrations of hemoglobin ferritin zinc folate and vitamin B-12. MAIN OUTCOME MEASURES: Covariates associated with anemia and micronutrient deficiencies in bivariate analyses were evaluated in multivariate logistic regression models adjusting for potential confounders. RESULTS: Anemia was present in 28% of the women 55% were zinc deficient 46% were vitamin B-12 deficient and 18% were folate deficient. Anemia was not associated with iron deficiency but rather with vitamin B-12 deficiency. Infestation with Ascaris was highly prevalent (67%) and associated with both folate and vitamin B-12 deficiency. Anemia and micronutrient deficiencies all varied significantly with season. CONCLUSIONS: The high prevalences of zinc and vitamin B-12 deficiencies in early pregnancy are a concern as it could lead to adverse pregnancy outcomes and increased health risks for both mother and child. The prevalence of iron deficiency was low but as this was during early pregnancy the women might develop iron deficiency and consequently iron deficiency anemia as the pregnancy progresses. (c) 2010 The Authors Acta Obstetricia et Gynecologica Scandinavica(c) 2010 Nordic Federation of Societies of Obstetrics and Gynecology.
TL;DR: Stage III–IV was strongly associated with poor IVF outcome, suggesting a decreased fertilization rate in stage I–II might be a cause of subfertility in these women, owing to a hostile environment caused by the disease.
Abstract: Objective. Endometriosis is a frequent indication for in vitro fertilization and embryo transfer (IVF-ET). Its influence on IVF-ET cycles remains controversial. We evaluated the impact of the severity of endometriosis on IVF-ET cycles in young women. Design. Retrospective cohort study. Setting. Academic tertiary referral centre. Sample and Methods. In a retrospective cohort analysis, 164 IVF-ET cycles in 148 women with endometriosis-associated infertility were analyzed. Eighty cycles performed during the same period on 72 consecutive women with tubal infertility were considered as controls. All patients were younger than 35 years old.Main Outcome Measures. Response to controlled ovarian hyperstimulation (COH), number of oocytes retrieved, fertilization, implantation and pregnancy rate (PR). Results. Clinical PR was lower in the group with endometriosis (all stages) in comparison with the tubal factor group. Higher total gonadotropin requirements, lower response to COH and lower oocyte yield were also found in the endometriosis group.Stage-stratifiedanalysisshowedalowerfertilizationrateinstageI‐II(52.6% stageI‐II,70.5%stageIII‐IVand71.9%tubalfactor).InstageIII‐IVendometriosis there was a higher cycle cancellation rate, a reduced response to COH and a lower PR compared with both the stage I‐II and the tubal infertility groups (PR 9.7, 25 and 26.1%, respectively). Conclusions. Stage III‐IV was strongly associated with poor IVF outcome. A decreased fertilization rate in stage I‐II might be a cause of subfertility in these women, owing to a hostile environment caused by the disease. Abbreviations: ASRM, American Society for Reproductive Medicine; COH, controlled ovarian hyperstimulation; E2, estradiol; FSH, follicle-stimulating hormone; hCG, human chorionic gonadotropin; IVF, in vitro fertilization; IVF-ET, in vitro fertilization and embryo transfer; PR, pregnancy rate
TL;DR: Urinary incontinence and urgency have a negative impact on women's sexual life and a dialogue about sexual function in women with urinary symptoms should become an integral component in clinical management.
Abstract: Objectives. To investigate the impact of urinary incontinence (UI) and urgency on women's sexual life and the prevalence of urinary leakage during sexual activity. A further aim was to explore fact ...
TL;DR: A tendency towards increased inflammation in pre‐eclampsia is supported, but the measured cytokines are not eligible for prediction, monitoring or diagnosing pre‐ eclampsIA.
Abstract: Objective. To evaluate differences in plasma cytokine levels longitudinally in pre-eclamptic and normotensive pregnancies. An increased inflammatory response has long been associated with pre-eclampsia, both early and late in the pre-eclamptic pregnancy. Design. Blood samples were collected longitudinally during pregnancy from a cohort of 1 631 pregnant women. Thirty-two women with pre-eclampsia and 67 normotensive pregnant women were identified from the cohort. Setting. A Danish regional hospital. Samples. Samples were collected from the 18th week of pregnancy until delivery and divided into the following four gestational intervals: 36th week. Methods. Simultaneous measurement of all nine cytokines was done using a capture bead system. Main Outcome Measures. Plasma levels of interleukin (IL)-1β, IL-2, IL-4, IL-6, IL-8, IL-10, tumor necrosis factor-α, interferon-γ and granulocyte macrophage colony-stimulating factor during pre-eclamptic and normotensive pregnancies. Results. Pre-eclampsia was associated with increased tumor necrosis factor-α between the 26th and 29th week (p=0.0421) and increased IL-6 after the 36th week (p=0.0044). The other cytokines measured were comparable in the two groups. Conclusions. This large prospective collection of blood samples was undertaken to determine inflammatory status during pre-eclamptic and normotensive pregnancies. Our results support a tendency towards increased inflammation in pre-eclampsia, but the measured cytokines are not eligible for prediction, monitoring or diagnosing pre-eclampsia.
TL;DR: In pregnancies with mild or severe preeclampsia, a large proportion of the placentas had histological signs of pathology, in particular signs of ischemia, suggesting mild and severe preeClampsia to have similar underlying etiology.
Abstract: Objective. To correlate placental histopathology, in particular ischemic changes, with the clinical severity of preeclampsia. Design. A blinded retrospective study. Setting. One Swedish hospital. Sample. One hundred and fifty-seven women with severe (n = 116) or mild (n = 41) preeclampsia and 157 normotensive women matched according to gestational-age. Methods: One senior pathologist, blinded to clinical data and group, examined all histological slides. In the statistical analyses, adjustment for gestational week was done when appropriate. Main outcome measures. Placental histopathological findings. Results: Amount of infarction increased with the severity of preeclampsia (p < 0.001). Infarction involving ≥ 5% of the placental tissue was seen in 39.7% of severe preeclampsia, 17.1% of mild preeclampsia and 5.1 % of non-preeclampsia. When comparing placentas in severe preeclampsia, mild preeclampsia and non-preeclampsia, there was an increase in the presence of any infarction (80.2%, 61.0%, vs. 20.4%). Also, there was a difference in the presence of decidual arteriopathy (35.3%, 22.0%, vs. 3.8%) and accelerated villous maturation (71.6%, 53.3%, vs. 12.6%). We found no difference in intervillous thrombosis, abruption placenta or placental weight in relation to gestational week. Conclusions. In pregnancies with mild or severe preeclampsia, a large proportion of the placentas had histological signs of pathology, in particular signs of ischemia. The pathology was similar, but more pronounced in severe compared to mild preeclampsia, suggesting mild and severe preeclampsia to have similar underlying etiology.
TL;DR: The presence of symptoms is more useful in predicting complications in preeclampsia compared to their absence in excluding adverse events, and a bivariate model estimating sensitivity, specificity and area under the curve is used.
Abstract: Background. Maternal symptoms such as severe headache, nausea and vomiting, visual disturbances and epigastric pain have been associated with complications in women with preeclampsia. Objective. To determine the accuracy of maternal symptoms in predicting complications in women with preeclampsia by systematic review. Data Sources.We searched MEDLINE (1951–2010), EMBASE (1980–2010), theCochraneLibrary(2009)andtheMEDIONdatabase.MethodsofStudySelection. Studies which evaluated the accuracy of symptoms in women with preeclampsia for predicting complications were selected in a two-stage process. Information was extracted by two independent reviewers. We summarized accuracy with a bivariate model estimating sensitivity, specificity and area under the curve. Results. Six primary articles with 2573 women were included. The area under the curve for predicting complications for headache, epigastric pain and visual disturbances was 0.58 (95%CI 0.24–0.86), 0.70 (95%CI 0.30–0.93) and 0.74 (95%CI 0.33–0.94). The sensitivityandspecificityofthesymptomsinpredictingadversematernaloutcomes were respectively as follows: headache 0.54 (95%CI 0.27–0.79) and 0.59 (95%CI 0.38–0.76); epigastric pain 0.34 (95%CI 0.22–0.5) and 0.83 (95%CI 0.76–0.89); visual disturbances 0.27 (95%CI 0.07–0.65) and 0.81 (95%CI 0.71, 0.88); nausea andvomiting0.24(95%CI0.21,0.27)and0.87(95%CI0.85,0.89).Conclusion.The presence of symptoms is more useful in predicting complications in preeclampsia compared to their absence in excluding adverse events. Abbreviations: AUC, area under the curve; CI, confidence interval; DIC, disseminated intravascular coagulation; HELLP, hemolysis, elevated liver enzymes, low platelets;ROC,receiveroperatingcharacteristiccurve;RR,relativerisk;sROC,summary receiver operating characteristic; TIPPS, Tests In Prediction of Preeclampsia’s Severity.
TL;DR: Obesity increases the risk of post‐cesarean infections and diabetes further strengthens this association, and obesity among diabetic women is higher than non‐obese women.
Abstract: Objective. To assess the impact of obesity and diabetes on the risk of post-cesarean infections. Design. Prospective cohort study. Setting. Obstetric departments at three hospitals in Denmark. Population. 2,492 consecutive women having cesarean section (CS) from February 2007 to August 2008. Methods. We collected complete data from medical records and databases on CS, body mass index, diabetes (type 1, type 2, and gestational), and post-cesarean infections. Post-discharge infections diagnosed by general practitioners were ascertained through positive microbiological cultures and antibiotic prescriptions. Main Outcome Measures. Cumulative incidences of infections within 30 days after CS. Results. Of 2,492 women having CS, 373 (15.2%) were obese and 123 (4.9%) had diabetes. Overall, 458 women (18.4%) had a post-cesarean infection within 30 days and 174 (7.0%) were diagnosed in-hospital. The risk of post-cesarean infections was higher among obese than non-obese women: adjusted (for diabetes and emergency/elective CS) odds ratio (OR)=1.43; 95% confidence interval (CI): 1.09–1.88, particularly for in-hospital infections (OR=1.86; 95%CI: 1.28–2.72). After controlling for obesity and mode of CS, type 2 or gestational diabetes were weak predictors of infection risk (OR=1.18; 95%CI: 0.72–1.93), whereas the adjusted OR in women with type 1 diabetes was 1.65 (95%CI: 0.64–4.25). Among diabetic women, obesity increased the risk of post-cesarean infections more than twofold; the adjusted ORs were 2.06 (95%CI: 1.13–3.75) for infections overall and 2.74 (95%CI: 1.25–6.01) for in-hospital infections. Conclusion. Obesity increases the risk of post-cesarean infections and diabetes further strengthens this association.
TL;DR: This is the first validated translation of the PFIQ‐7, PFDI‐20 and PISQ‐12 in Swedish, and all three instruments indicated acceptable psychometric properties.
Abstract: Objective. To psychometrically evaluate the Swedish translations of the short forms of the Pelvic Floor Impact Questionnaire (PFIQ-7), Pelvic Floor Distress Inventory (PFDI-20) and Pelvic organ prolapse/Urinary incontinence Sexual questionnaire (PISQ-12). Design and setting. University hospital. Sample. Forty-four patients awaiting prolapse surgery. Methods. The dual panel translation method followed by an evaluation of validity and reliability in prolapse patients. Main outcome measures. Construct, convergent and discriminant validity, reliability via test-retest and internal consistency. Results. Item response rates were high (range: 95.5-100%) for PFIQ-7 and PFDI-20. The corrected item-total correlations showed acceptable construct validity for PFIQ-7 (r= 0.338-0.826) but low for PFDI-20 (r= 0.116-0.581) and PISQ-12 (r= 0.024-0.735). Acceptable convergent validity was found in all three instruments with a negative correlation with the SF-12. There were no floor- or ceiling effects in the three instruments. In the test-retest analysis intraclass correlation coefficients (ICC) were significant (r= 0.888 - 0.943). Cronbach´s alpha varied between 0.57 and 0.94. Conclusion. This is the first validated translation of the PFIQ-7, PFDI-20 and PISQ-12 in Swedish. All three instruments indicated acceptable psychometric properties. (Less)
TL;DR: Sacrospinous vaginal fixation provides good long‐term objective and subjective outcomes and improves quality of life of women with pelvic organ prolapse and has a definite place in modern pelvic reconstructive surgery.
Abstract: There has been a trend towards increased use of synthetic meshes and abdominal procedures with decreased use of sacrospinous fixation (SSF). A Medline search was performed for the MeSH terms 'sacrospinous ligament', 'sacrospinous fixation', 'sacrospinous ligament suspension' and 'sacrospinous colpopexy'. Published papers from 1996-2010 were selected for analysis. Outcome measures were assessed in terms of efficacy, complications and quality of life after sacrospinous vaginal fixation. Studies on bilateral SSF and fixing uterus to the sacrospinous ligament, use of concomitant anti-incontinence procedures along with SSF were not included in this review. Sacrospinous vaginal fixation provides good long-term objective and subjective outcomes and improves quality of life of women with pelvic organ prolapse. Further, complication rates of SSF are comparable to abdominal sacrocolpopexy and are much less than transvaginal mesh procedures and SSF is a cost-effective procedure. SSF is a time-tested surgical procedure with a reduction in surgical extent and has a definite place in modern pelvic reconstructive surgery.
TL;DR: A two‐day ALSO training course can significantly improve staff performance and reduce the incidence of PPH, at least as evaluated by short‐term effects.
Abstract: Objective To evaluate the impact of Advanced Life Support in Obstetrics (ALSO) training on staff performance and the incidences of post-partum hemorrhage (PPH) at a regional hospital in Tanzania. Design Prospective intervention study. Setting A regional, referral hospital. Population A total of 510 women delivered before and 505 after the intervention. Methods All high- and mid-level providers involved in childbirth at the hospital attended a two-day ALSO provider course. Staff management was observed and post-partum bleeding assessed at all vaginal deliveries for seven weeks before and seven weeks after the training. Main outcome measures PPH (blood loss ≥500ml), severe PPH (blood loss ≥1000ml) and staff performance to prevent, detect and manage PPH. Results The incidence of PPH was significantly reduced from 32.9 to 18.2%[RR 0.55 (95%CI: 0.44-0.69)], severe PPH from 9.2 to 4.3%[RR 0.47 (95%CI: 0.29-0.77)]. The active management of the third stage of labor was also significantly improved. There was a significant decrease in episiotomies. By visual estimation, staff identified one in 25 of the PPH cases before the ALSO training and one in five after the training. A significantly higher proportion of women with PPH had continuous uterine massage, oxytocin infusion and bimanual compression of the uterus after the training. Conclusions A two-day ALSO training course can significantly improve staff performance and reduce the incidence of PPH, at least as evaluated by short-term effects.
TL;DR: It is concluded that in the population, restless legs syndrome in pregnancy is both frequent and transient, occurring in approximately one in three pregnancies and typically resolving within a few days after delivery.
Abstract: The aim of this study was to assess the prevalence of restless legs syndrome in pregnancy. We distributed a questionnaire to 541 consecutive postpartum patients and received answers from 251 (46%) women. Of the participants, 34% reported restless legs syndrome in pregnancy. In 97% of the women in whom restless legs syndrome had started during the pregnancy, the symptoms disappeared within two to three days after delivery. There was no correlation between pregnancy-related restless legs syndrome and low hemoglobin levels in the first trimester, and the incidence of restless legs syndrome was not affected by use of iron supplementation. We conclude that in our population, restless legs syndrome in pregnancy is both frequent and transient, occurring in approximately one in three pregnancies and typically resolving within a few days after delivery.