Showing papers in "Acta Obstetricia et Gynecologica Scandinavica in 2014"

Management of placenta percreta: a review of published cases

Abstract: Publications on abnormally invasive placenta in general report what can be considered a mixture of the conditions true accreta, increta and percreta varieties. The aim of this review was to identify all published cases of the most severe condition, placenta percreta in order to describe complications associated with the three commonly used surgical strategies: local resection, hysterectomy or leaving the placenta in situ, and to describe the outcome, with respect to blood loss and transfusion requirements, with the different endovascular interventions that may be used as adjuncts in the management of the conditions. A PubMed search was performed in April 2013 and the final review included 119 published placenta percreta cases. Conservative management, where the placenta is left in situ for resorption, seems to be associated with severe long-term complications of hemorrhage and infections, including a 58% risk that a hysterectomy will eventually be needed up till nine months after the delivery. Local resection seems to be associated with fewer complications within 24 h postoperatively compared with hysterectomy or leaving the placenta in situ. A selection bias in the direction of less severe cases for the local resection technique might in part explain the lower complication rates with that approach. Future prospective data collection activities should include intended as well as actual management, and long-term follow-up of all cases is of vital importance.

Deprived neighborhoods and adverse perinatal outcome: A systematic review and meta-analysis

Abstract: Objectives This study aims to summarize evidence on the relation between neighborhood deprivation and the risks for preterm birth, small-for-gestational age, and stillbirth. Design The design was a systematic review and meta-analysis. Main outcome measures The main outcome measures included studies that directly compared the risk of living in the most deprived neighborhood quintile with least deprived quintile for at least one perinatal outcome of interest (preterm delivery, small-for-gestational age and stillbirth). Methods Study selection was based on a search of Medline, Embase and Web of Science for articles published up to April 2012, reference list screening, and email contact with authors. Data on study characteristics, outcome measures, and quality were extracted by two independent investigators. Random-effects meta-analysis was performed to estimate unadjusted and adjusted summary odds ratios with the associated 95% confidence intervals. Results We identified 2863 articles, of which 24 were included in a systematic review. A meta-analysis (n = 7 studies, including 2 579 032 pregnancies) assessed the risk of adverse perinatal outcomes by comparing the most deprived neighborhood quintile with the least deprived quintile. Compared with the least deprived quintile, odds ratios for adverse perinatal outcomes in the most deprived neighborhood quintile were significantly increased for preterm delivery (odds ratio 1.23, 95% confidence interval 1.18-1.28), small-for-gestational age (odds ratio 1.31, 95% confidence interval 1.28-1.34), and stillbirth (odds ratio 1.33, 95% confidence interval 1.21-1.45). Conclusions Living in a deprived neighborhood is associated with preterm birth, small-for-gestational age and stillbirth.

The relation between endometriosis and ovarian cancer – a review

Abstract: Background Endometriosis is known to harbor characteristics substantiating its possible role as a precursor of ovarian cancer. Objective To assess the quality of the literature regarding the association between endometriosis and ovarian cancer and to estimate the extent of this relation. Methods An electronic literature search was conducted in PubMed and 1112 articles dealing with the relation between endometriosis and ovarian cancer were identified. Original articles based on case-control studies, cohort studies and cross-sectional studies were included. Studies consisting of populations with self-reported endometriosis were excluded, as were articles with fewer than 20 cases of ovarian cancer. Twenty-eight studies underwent detailed quality assessments based on the checklists developed by the Scottish Intercollegiate Guidelines Network (SIGN). Meta-analyses were conducted on selected subgroups of ovarian cancer with coexisting endometriosis. Results None of the 28 studies was given the highest possible rating using the SIGN checklists. The risk of ovarian cancer in women with endometriosis was reported to be a standardized incidence ratio of 1.43–8.95, a rate ratio of 1.6–2.88, an odds ratio of 1.34, with a prevalence of ovarian cancer in 2.0–17.0% of women with endometriosis. Conversely, the prevalence of endometriosis in women with ovarian cancer ranged from 3.4 to 52.6%. Meta-analysis results were weakened by heterogeneity. Conclusion There is sufficient evidence to conclude that there is an increased risk of developing clear-cell and endometrioid epithelial ovarian cancer for women with histologically verified endometriosis. Nonetheless, prospective cohort studies assessing the relation between endometriosis and ovarian cancer will increase knowledge in this field.

The Nordic medical birth registers – a potential goldmine for clinical research

Abstract: The Nordic medical birth registers have long been used for valuable clinical research. Their collection of data for more than four decades offers unusual possibilities for research across generations. At the same time, serum and blotting paper blood samples have been stored from most neonates. Two large cohorts (approximately 100000 births) in Denmark and Norway have been described by questionnaires, interviews and collection of biological samples (blood, urine and milk teeth), as well as a systematic prospective follow-up of the offspring. National patient registers provide information on preceding, underlying and present health problems of the parents and their offspring. Researchers may, with permission from the national authorities, obtain access to individualized or anonymized data from the registers and tissue-banks. These data allow for multivariate analyses but their usefulness depends on knowledge of the specific registers and biological sample banks and on proper validation of the registers. (Less)

Heavy menstrual bleeding significantly affects quality of life.

Abstract: Objective To investigate the prevalence of women subjectively experiencing heavy menstrual bleeding in the general population and their health-related quality of life (HRQoL) compared with women experiencing normal menstrual blood loss. Design Community-based cross-sectional descriptive survey on a randomized sample of the Swedish general population. Settings Invitation by e-mail to join an online questionnaire in Sweden, conducted in June 2012. Population 1547 women, aged 40–45 years old. Methods Web-based questionnaire consisting of disease-specific questions, concerning the perceptions of menstrual bleeding, in combination with the generic Short Form-36v2 (SF-36) Health Survey Questionnaire to evaluate HRQoL. Results We found that 32% of women experienced heavy menstrual bleeding, 39% normal menstrual blood loss, 15% light menstrual blood loss and 14% no menstruation. In general, menstrual bleeding was associated with negative perceptions and limited social and professional activities, although all areas were significantly more affected in women experiencing heavy menstrual bleeding than normal menstrual bleeding. The SF-36 showed that women experiencing heavy menstrual bleeding had significantly worse HRQoL compared with women with normal menstrual bleeding in all domains. Conclusion Of women 40–45 years old, 32% experience heavy menstrual bleeding. These women have significantly worse HRQoL compared with women with normal menstruation patterns.

Implementing a structured Enhanced Recovery After Surgery (ERAS) protocol reduces length of stay after abdominal hysterectomy

Abstract: Objective: To study the effects of introducing an Enhanced Recovery After Surgery (ERAS) protocol, modified for gynecological surgery, on length of stay and complications following abdominal hyster ...

Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study.

Abstract: Objective.The aim of this study was to evaluate the effect of the increased cesarean rate for term breech presentation on neonatal outcome. We also investigated whether the clinical case selection for vaginal delivery applied by Dutch obstetricians led to an optimization of neonatal outcome, or whether there is still room for improvement in terms of perinatal outcome.Design.Retrospective cohort.Setting.The Netherlands.Population.Singleton term breech deliveries from 37 +0 to 41 +6 weeks, excluding fetuses with congenital malformations or antenatal death.Method.We used data from the Dutch national perinatal registry from 1999 up to 2007.Main outcome measures.Perinatal mortality and morbidity.Results.We studied 58 320 women with a term breech delivery. There was an increase in the elective cesarean rate (from 24 to 60%). As a consequence, overall perinatal mortality decreased [1.3v odds ratio 0.51 (95% confidence interval 0.28‐0.93)], whereas it remained stable in the planned vaginal birth group [1.7v odds ratio 0.96 (95% confidence interval 0.52‐1.76)]. The number of cesareans done to prevent one perinatal death was 338.Conclusions.Adjustment of the national guidelines after publication of the Term Breech Trial resulted in a shift towards elective cesarean and a decrease of perinatal mortality and morbidity among women delivering a child in breech at term. Still, 40% of these women attempt vaginal birth. The relative safety of an elective cesarean should be weighed against the consequences of a scarred uterus in future pregnancies. Abbreviations:CI, confidence interval; OR, odds ratio; PRN, Netherlands Perinatal Registry; RR, relative risk.

Reduced quality of life when experiencing menstrual pain in women with primary dysmenorrhea

Abstract: Primary dysmenorrhea is the most common gynecological condition among women of reproductive age. Although dysmenorrhea has been reported to affect the ability of women to carry out daily activities, the impact of primary dysmenorrheic pain specifically on quality of life (QoL), has yet to be elucidated. We investigated whether QoL varies between women with and without severe primary dysmenorrhea, and whether QoL is impaired only during menstruation or also during pain-free phases of the menstrual cycle. Twelve women with severe primary dysmenorrhea and nine control women completed the quality of life enjoyment and satisfaction questionnaire (Q-LES-Q-SF) during menstruation and during the late follicular phase. Women with dysmenorrhea had a significant reduction in Q-LES-Q-SF scores (mean ± SD: 54 ± 18%, percentage of the total maximum possible score) when they were experiencing severe menstrual pain compared with their own pain-free follicular phase (80 ± 14%, p < 0.0001) and compared with controls during menstruation (81 ± 10%, p < 0.0001). They also rated their overall life satisfaction and contentment as poorer during menstruation. Severe menstrual pain associated with primary dysmenorrhea, therefore, impacts health-related of QoL.

Impact of fetal and neonatal environment on beta cell function and development of diabetes

Abstract: The global epidemic of diabetes is a serious threat against health and healthcare expenses. Although genetics is important it does not explain the dramatic increase in incidence, which must involve environmental factors. Two decades ago the concept of the thrifty phenotype was introduced, stating that the intrauterine environment during pregnancy has an impact on the gene expression that may persist until adulthood and cause metabolic diseases like obesity and type 2 diabetes. As the pancreatic beta cells are crucial in the regulation of metabolism this article will describe the influence of normal pregnancy on the beta cells in both the mother and the fetus and how various conditions like diabetes, obesity, overnutrition and undernutrition during and after pregnancy may influence the ability of the offspring to adapt to changes in insulin demand later in life. The influence of environmental factors including nutrients and gut microbiota on appetite regulation, mitochondrial activity and the immune system that may affect beta cell growth and function directly and indirectly is discussed. The possible role of epigenetic changes in the transgenerational transmission of the adverse programming may be the most threatening aspect with regard to the global diabetes epidemics. Finally, some suggestions for intervention are presented.

Postpartum weight retention and breastfeeding among obese women from the randomized controlled Lifestyle in Pregnancy (LiP) trial.

Abstract: Objectives. To study the effects of lifestyle intervention in pregnancy on weight retention 6 months postpartum among obese women from the “Lifestyle in Pregnancy” (LiP) study, and to determine associations between breastfeeding with postpartum maternal weight. Design. Six months postpartum follow up after a randomized controlled intervention trial. Setting. Two university hospitals in Denmark. Population. A total of 360 women with pregestational body mass index ≥30 kg/m 2 . Methods. The intervention involved lifestyle changes (diet and exercise) during pregnancy. The control group received routine pregnancy care. Both groups received standard postnatal care. Main outcome measures. Gestational weight gain, postpartum weight retention and breastfeeding. Results. Follow up was completed in 238 women of whom 46% in the intervention group and 57% in the control group had retained weight 6 months postpartum (p = 0.088). Women with gestational weight gain ≤9 kg, (recommended by the Institute of Medicine), retained less postpartum weight compared with those who exceeded 9 kg (median 0.7 vs. 1.5, p 5 kg (94% vs. 85%, p = 0.034). Conclusions. We could not detect sustained weight control at 6 months postpartum despite a lower gestational weight gain for obese women during pregnancy who received a lifestyle intervention rather than standard care. Women who adhered to gestational weight gain recommendations had significantly lower postpartum weight retention. Breastfeeding for 6 months was negatively associated with postpartum weight retention.

Women with greater pelvic floor muscle strength have better sexual function.

Abstract: Objective To investigate the relation between pelvic floor muscle strength and sexual function among women with higher and lower pelvic floor muscle strength. Design A cross-sectional study was performed among employees and students of the University. Setting Urogynecology department, Federal University of Pampa, Brazil, carried out between January and July of 2012. Population Forty women, aged 20–28 years. Methods Forty-nine women were screened and nine were excluded. Baseline information of the participants was obtained. The Female Sexual Function Index questionnaire was applied and pelvic floor muscle strength was randomly measured by transvaginal palpation according to the Ortiz scale, and by perineometry. Women were allocated into two groups according to muscle strength. Main outcome measures Index of sexual function and pelvic floor muscle strength Results Women with stronger pelvic floor muscles scored higher in the following domains: desire, excitement, orgasm and general score of the questionnaire (4.9 ± 0.73 vs. 3.8 ± 0.58; 5.0 ± 0.35 vs. 4.3 ± 0.82; 5.8 ± 0.21 vs. 4.0 ± 1.00 and 32.4 ± 0.77 vs. 27.6 ± 3.29, p < 0.001). There was a moderate correlation between pelvic floor muscle pressure and both sexual satisfaction (r = 0.47, p = 0.03) and lubrication (r = −0.69, p = 0.001) as well as the manual evaluation of pelvic floor muscle strength, graded by the Ortiz and perineometry, which were interrelated (r = 0.65, p = 0.001). Conclusion Our findings suggest that women with stronger pelvic floor muscles have better sexual function.

The International Network of Obstetric Survey Systems (INOSS): benefits of multi-country studies of severe and uncommon maternal morbidities

Abstract: The International Network of Obstetric Survey Systems (INOSS) is a multi-country collaboration formed to facilitate studies of uncommon and severe complications of pregnancy and childbirth. Collaborations such as INOSS offer many benefits in the study of rare complications. The use of uniform case definitions, common datasets, specifically collected detailed data and prospectively agreed comparative and combined analyses all add to the validity of studies and their utility to guide policy and clinical practice and hence improve the quality of care. Such multi-national collaborations allow for the conduct of robust studies less subject to many of the biases attributed to typical observational studies. For very rare conditions such collaborations may provide the only route to providing high quality evidence to guide practice. Clinicians and researchers conducting studies into rare and severe complications should consider working through a network such as INOSS to maximize the value of their research.

Rheumatoid arthritis and outcomes in first and subsequent births based on data from a national birth registry

Abstract: Objective To examine associations between rheumatoid arthritis (RA) and pregnancy outcomes in first and subsequent births. Design Cohort study. Setting Study based on data registered in the Medical Birth Registry of Norway from the period 1 December 1998 to 31 December 2009. Population Singleton births in women recorded with RA (n = 1496) and reference deliveries from the general population (n = 625 642). Methods Outcomes of first and subsequent births were analyzed separately. First birth was defined as the first delivery of nulliparous women. Associations between RA and maternal and perinatal outcomes were assessed in logistic regression analyses and adjusted for maternal age at delivery, gestational age, smoking habits and for previous cesarean section when relevant. Main outcome measures Maternal and perinatal outcomes. Results Vaginal bleeding was observed more often among women with RA both in first pregnancy [adjusted odds ratio (aOR) 1.8, 95% CI 1.3–2.4] and in subsequent pregnancies (aOR 1.4, 95% CI 1.1–1.9). Elective cesarean section was more common among women with RA both in the first birth (aOR 2.0, 95% CI 1.4–2.8) and in subsequent births (aOR 1.5, 95% CI 1.2–2.0). Preterm delivery was more frequent among women with RA than the reference population in first pregnancy (aOR 1.5, 95% CI 1.1–2.0) and in subsequent pregnancies (aOR 1.5, 95% CI 1.1–1.9). Conclusion Complications and poor pregnancy outcomes were more often observed in women with RA and the greatest differences were observed in the first pregnancy.

Childhood consequences of maternal obesity and excessive weight gain during pregnancy

Abstract: Obesity is a major public health concern. In western countries, the prevalence of obesity in pregnant women has strongly increased, with reported prevalence rates reaching 30%. Also, up to 40% of women gain an excessive amount of weight during pregnancy. Recent observational studies and meta-analyses strongly suggest long-term impact of maternal obesity and excessive weight gain during pregnancy on adiposity, cardiovascular and respiratory related health outcomes in their children. These observations suggest that maternal adiposity during pregnancy may program common health problems in the offspring. Currently, it remains unclear whether the observed associations are causal, or just reflect confounding by family-based sociodemographic or lifestyle-related factors. Parent-offspring studies, sibling comparison studies, Mendelian randomization studies and randomized trials can help to explore the causality and underlying mechanisms. Also, the potential for prevention of common diseases in future generations by reducing maternal obesity and excessive weight gain during pregnancy needs to be explored.

Inter- and intra-observer agreement of non-reassuring cardiotocography analysis and subsequent clinical management.

Abstract: Objective. To quantify inter- and intra-observer agreement of non-reassuring intrapartum cardiotocography (CTG) patterns and subsequent clinical management. Design. Methodological study. Setting. University Medical Center. Population. CTG patterns of 79 women beyond 37 weeks of gestation with a singleton fetus in vertex position in first stage of labor in whom fetal blood sampling (FBS) had been performed.Methods. Nine observers assessed CTG patterns, which were formerly clinically classified as non-reassuring and indicative for FBS, according to the guidelines of the International Federation of Gynecology and Obstetrics modified for ST analysis. They also proposed clinical management strategies without and with insight into clinical parameters. Weighted kappa values (jw) and proportions of agreement (Pa) were calculated. Main outcome measures. Agreement on CTG classification and clinical management. Results. Inter-observer agreement on CTG classification and on clinical management were poor for most observer categories (jw range 0.31–0.50 and 0.20–0.45, respectively). Observers agreed best on abnormal CTG patterns (Pa range 0.28–0.36) and on the clinical management option “continue monitoring” (Pa range 0.32–0.40). Intra-observer agreement was fair to good for most observers (jw 0.33–0.70). Insight into clinical parameters resulted in similar inter- and intra-observer agreement. Conclusions. There was poor inter-observer agreement and fair to good intra-observer agreement on classification and clinical management of intrapartum CTG patterns, which had been classified as non-reassuring and indicative for FBS during birth. Abbreviations: CTG, cardiotocography; FBS, fetal blood sampling; FIGO/STAN guidelines, guidelines of the International Federation of Gynecology and Obstetrics modified for ST analysis; jw, weighted kappa (in case of three categories weights 1, 0.5 and 0, in case of four categories weights 1, 0.66, 0.33 and 0); Pa, proportions of agreement; CI, confidence interval; RUNMC, Radboud University Nijmegen Medical Center.

The cervical mucus plug inhibits, but does not block, the passage of ascending bacteria from the vagina during pregnancy

Abstract: Objective To evaluate the microbial load and the inflammatory response in the distal and proximal parts of the cervical mucus plug. Design Experimental research. Population Twenty women with a normal, singleton pregnancy. Sample Vaginal swabs and specimens from the distal and proximal parts of the cervical mucus plug. Methods Immunohistochemistry, enzyme-linked immunosorbent assay, quantitative polymerase chain reaction and histology. Results The total bacterial load (16S rDNA) was significantly lower in the cervical mucus plug compared with the vagina (p = 0.001). Among women harboring Ureaplasma parvum, the median genome equivalents/g were 1574 (interquartile range 2526) in the proximal part, 657 (interquartile range 1620) in the distal part and 60 240 (interquartile range 96 386) in the vagina. Histological examinations and quantitative polymerase chain reaction revealed considerable amounts of lactobacilli and inflammatory cells in both parts of the cervical mucus plug. The matrix metalloproteinase-8 concentration was decreased in the proximal part of the plug compared with the distal part (p = 0.08). Conclusion The cervical mucus plug inhibits, but does not block, the passage of Ureaplasma parvum during its ascending route from the vagina through the cervical canal.

Desogestrel‐only contraceptive pill versus sequential contraceptive vaginal ring in the treatment of rectovaginal endometriosis infiltrating the rectum: a prospective open‐label comparative study

Abstract: OBJECTIVE: To compare the efficacy of two hormonal therapies in treating symptoms caused by bowel endometriosis. DESIGN: Patient preference study. SETTING: University hospital. POPULATION: A total of 143 women with rectovaginal endometriosis infiltrating the rectum. METHODS: This study was performed between January 2008 and June 2011. Patients were treated with a desogestrel-only contraceptive pill or with the sequential combined contraceptive vaginal ring for 12 months. MAIN OUTCOME MEASURES: The primary endpoint of the study was the rate of satisfied patients at 12-month follow up. The changes in symptoms and in the volume of the nodules were secondary endpoints. RESULTS: At 12-month follow up the rate of satisfied patients was higher in the group treated with the desogestrel-only contraceptive pill than in the group treated with the sequential combined contraceptive vaginal ring (p = 0.004). When only changes in gastrointestinal symptoms were considered 50% of patients treated with the desogestrel-only contraceptive pill and 31.3% of those treated with the sequential combined contraceptive vaginal ring were satisfied (p = 0.037). The reduction in the volume of the nodules the percentages of patients who discontinued the therapy after the completion of the study and of those who decided to undergo surgery were similar between the two groups. CONCLUSIONS: Both hormonal therapies are efficacious in treating symptoms caused by rectovaginal endometriosis infiltrating the rectum. Patient satisfaction is higher with the desogestrel-only pill than with a vaginal ring. (c) 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

Reproductive prognosis in endometriosis. A national cohort study.

Abstract: Objective To assess the reproductive long-term prognosis of women with and without endometriosis, to explore changes over time, and to quantify the contribution of artificial reproductive techniques. Design Cohort study. Setting Denmark 1977–2009. Sample Data retrieved from four national registries. Among 15–49-year-old women during the period 1977–82, 24 667 were diagnosed with endometriosis and 98 668 (1:4) women without endometriosis were age-matched. Methods To assess long-term reproductive prognosis, all pregnancy outcomes were identified among the women with and without endometriosis until the end of 2009. To explore changes over time, the endometriosis cohorts were followed for 15 years from the years 1980, 1986, 1992 and 1998, with the corresponding control cohorts. All pregnancy outcomes were categorized into naturally or artificially conceived pregnancies. Main outcome measures Births, miscarriages, induced abortions, ectopic pregnancies and hydatidiform moles. Results Compared with women without endometriosis, women with endometriosis had a lowered relative risk for childbirth of 0.93 (95% confidence interval 0.92–0.95), for miscarriages the relative risk was 1.2 (95% confidence interval 1.2–1.3), ectopic pregnancies were almost twice as many (relative risk 1.9, 95% confidence interval 1.8–2.1), while frequencies of induced abortions were equivalent. The chances for childbirth increased over time from 0.82 to 0.92 (p < 0.001) with successive cohorts, but this was restricted to pregnancies from assisted reproduction. Conclusion Women with endometriosis have slightly fewer children, but this lessened over time due to artificially conceived pregnancies. The risk for miscarriages and ectopic pregnancies was increased compared with women without the disease.

Differential clinical characteristics, treatment response and prognosis of locally advanced adenocarcinoma/adenosquamous carcinoma and squamous cell carcinoma of cervix treated with definitive radiotherapy

Abstract: Objective To compare tumor characteristics and clinical outcome of patients with cervical locally advanced adenocarcinoma (AC)/adenosquamous carcinoma (ASC) and squamous cell carcinoma (SCC). Design Retrospective study. Setting National Taiwan University Hospital, Taipei, Taiwan. Population All patients with cervical SCC (n = 35), AC or ASC (n = 194) with FIGO stage ≥IIB who received definitive radiotherapy or concurrent chemoradiotherapy (CCRT) from January 1995 to December 2009. Method Medical and histopathological record review. Main outcome measures Progression-free survival (PFS), local recurrence-free survival, distant metastasis-free survival, and overall survival (OS). Results Compared with the SCC subgroup, patients with AC/ASC were significantly younger (p = 0.007), more of them without clinical symptoms were diagnosed by abnormal Pap smear findings (p = 0.043), and less responded to treatment (p = 0.018). After a median follow-up of 59.3 months, patients with AC/ASC had worse 5-year PFS (30.0% vs. 47.6%, p = 0.044), worse 5-year distant metastasis-free survival (41.5% vs. 69.9%, p = 0.005), and trends toward worse 5-year local recurrence-free survival (64.4% vs. 76.2%, p = 0.165) and worse 5-year OS (41.3% vs. 58.1%, p = 0.090) than patients with SCC. In univariate analysis, early FIGO stage and complete treatment response were significantly associated with PFS and OS. Histology of non-AC/ASC and Point A biologically equivalent doses in 2-Gy fractions >85 Gy were significantly associated with better PFS, and CCRT was significantly associated with better OS. In multivariate analysis, complete treatment response and early FIGO stage remained significant factors for predicting better PFS and OS. Conclusions Cervical AC/ASC may be more aggressive than is SCC. For cervical AC/ASC, more comprehensively effective treatments are warranted.

Trends in the prevalence of gestational diabetes mellitus in southern Sweden, 2003-2012.

Abstract: There is accumulating evidence that gestational diabetes (GDM) is a growing problem The lack of internationally standardized diagnostic procedures prevents consistent diagnosis and the burden of GDM must be determined in country-specific studies In southern Sweden, GDM is defined as a 2-hour capillary plasma glucose concentration of ≥100 mmol/L during a universal 75 g oral glucose tolerance test We report the crude prevalence of GDM during the years 2003-2012 Of 156 144 women who gave birth, 22% were diagnosed with GDM When the effect of time on the prevalence of GDM was assessed in a log-linear Poisson model, an overall increase in prevalence of 35% was predicted, corresponding to an average annual increase of 34% Predicted prevalence was 19 (95% CI 18-20) in 2003 and 26 (24-27) in 2012 (p<00001) Due to a simultaneous rise in birth rate, the number of women diagnosed with GDM increased by 64% This article is protected by copyright All rights reserved (Less)

Effects of anemia and iron deficiency on quality of life in women with heavy menstrual bleeding

Abstract: Objective To assess the impact of anemia and iron deficiency on health-related quality of life (HRQoL) in women treated for heavy menstrual bleeding (HMB). Design Secondary analysis of a randomized controlled trial. Setting Five university hospitals in Finland. Sample A total of 236 women referred for HMB. Methods Women were randomized to treatment with hysterectomy or a levonorgestrel-releasing intrauterine system. We defined groups based on women's pretreatment hemoglobin [hemoglobin <120 g/L (anemic) vs. hemoglobin ≥120 g/L (nonanemic)] and serum ferritin (ferritin <15 μg/L vs. ≥15 μg/L) concentrations. HRQoL was compared between groups at baseline, 6 and 12 months after treatment. Hemoglobin and ferritin were followed for 5 years. Main outcome measures HRQoL was measured by the RAND 36-item health survey (RAND-36), 5-Dimensional EuroQol and two questionnaires of mental wellbeing. Results At baseline, 63 women (27%) were anemic and 140 (60%) were severely iron deficient (ferritin <15 μg/L). Only 8% of the anemic women had taken iron supplementation. Twelve months after treatment hemoglobin had increased in both hemoglobin groups, but was still significantly lower (p < 0.001) in initially anemic women (128 g/L) compared with nonanemic women (136 g/L). Twelve months after treatment three domain scores of RAND-36 increased more (energy, p = 0.002; physical functioning, p = 0.04; social functioning, p = 0.05), and anxiety (p = 0.02) and depression scores (p = 0.002) decreased more in anemic compared with nonanemic women. Serum ferritin took 5 years to reach normal levels. Conclusions Improved HRQoL after treatment of HMB is associated with correction of anemia. Clinicians should actively screen for anemia in women with HMB and emphasize early iron substitution as an integral part of treatment.

Transversus abdominis plane block after ambulatory total laparoscopic hysterectomy: randomized controlled trial.

Abstract: Objective To determine if transversus abdominis plane anesthetic blockage (TAP block) diminishes early postoperative pain scores and facilitates ambulatory management following total laparoscopic hysterectomy. Design Randomized triple blind trial. Setting Gynecological endoscopy unit at a referral center for laparoscopic surgery. Population A total of 197 patients. Methods Comparison of a treatment group receiving TAP block with bupivacaine 0.25% and placebo group with comparably placed bilateral injection of sterile saline solution. Main outcome measures Pain scores at discharge 24, 48 and 72 h after surgery, opioid requirement after procedure. Results Patients who had TAP block had a significant reduction in their pain score at discharge compared with the placebo group (p = 0.017). There were no significant differences in the pain scores between groups at 24 h (95% CI 1.36–0.133, p = 0.237), 48 h (95% CI 0.689–0.465, p = 0.702) and 72 h (95% CI −0.631 to 0.223, p = 0.347). No differences were found between the groups regarding opioid requirements following the procedure (χ2 = 3.62, p = 0.46). Conclusion Although TAP block after a total laparoscopic hysterectomy reduced the pain score at discharge compared with placebo, its role in this setting is debatable due to the possible lack of clinical significance of the small difference found.

Maternal smoking in pregnancy and risk for congenital malformations: results of a Danish register-based cohort study.

Abstract: Objective To examine the association between maternal smoking during pregnancy and risk for congenital malformations. Design Population-based prospective cohort study. Setting Denmark. Population A total of 838 265 singleton liveborn babies delivered in Denmark between 1997 and 2010 and registered in the Danish Medical Birth Register containing detailed information on smoking during pregnancy and congenital malformations. Methods Associations [odds ratios (OR) with 95% CI] between maternal smoking and risk for various groups of congenital malformations, investigated using the generalized estimating equation for binary outcomes, with adjustment for potential confounders. Main outcome measures Groups of congenital malformations. Results Ever smoking during pregnancy did not increase the overall risk for congenital malformations, but increased risks were observed for multiple malformations (i.e. when two or more malformations are diagnosed in a child) (odds ratio 1.06, 95% confidence interval 1.01–1.10) and various main groups of congenital malformations including the cardiovascular system (odds ratio 1.13, 95% confidence interval 1.07–1.19), the respiratory system (odds ratio 1.25, 95% confidence interval 1.11–1.41), the digestive system (odds ratio 1.15, 95% confidence interval 1.07–1.24) and oral clefts (odds ratio 1.29, 95% confidence interval 1.14–1.46), as well as for some specific congenital malformations including cardiac septal defects, malformations of the pulmonary and tricuspid valves, malformations of the great arteries, pyloric stenosis and clubfoot. Infants of women who quit smoking during the first two trimesters had no increased risk for most groups of congenital malformations. Conclusions Maternal smoking increases the risk for a number of congenital malformations. Future smoking cessation programs should focus on this adverse health aspect in order to encourage more women to quit smoking before or in early pregnancy.

A randomized controlled trial on early induction compared to expectant management of nulliparous women with prolonged latent phases

Abstract: Objective To compare early induction and expectant management regarding delivery outcomes and the experience of delivery in nulliparous women with prolonged latent phases. Design Randomized controlled trial. Setting One delivery unit in a Swedish hospital. Population Nulliparous women at term experiencing continuous contractions impeding rest (women's report) and exceeding 18 h, a cervical dilation of less than 4 cm, intact membranes and with a singleton fetus in cephalic presentation. Methods The women were randomly allocated to either early induction (n = 65) or expectant management (n = 64). All participants received medication for therapeutic rest. The early induction group was induced five hours after medication, and the expectant group awaited spontaneous onset of labor. The Wijma Delivery Experience Questionnaire (W-DEQ version B) was filled in after delivery. Main outcome measures The primary outcome was mode of delivery. Secondary outcomes included birth experience, duration of labor, postpartum hemorrhage, and neonatal outcomes. Results The cesarean section rate was 15 of 65 (23.1%) in the early induction group and 24 of 64 (37.5%) in the expectant group (p = 0.076, OR 2.00, 95% CI 0.93–4.31). No significant differences were shown regarding delivery, neonatal outcomes or birth experience. Conclusions No significant differences were shown between the two groups in the rate of cesarean sections or the experience of delivery. According to the actual results, the power to detect a difference was only 45%. The cesarean section rate was high in both groups, regardless of intervention.

Influence of maternal body mass index on accuracy and reliability of external fetal monitoring techniques

Abstract: Objective To evaluate the performance of external electronic fetal heart rate and uterine contraction monitoring according to maternal body mass index. Design Secondary analysis of prospective equivalence study. Setting Three US urban teaching hospitals. Sample Seventy-four parturients with a normal term pregnancy. Methods The parent study assessed performance of two methods of external fetal heart rate monitoring (abdominal fetal electrocardiogram and Doppler ultrasound) and of uterine contraction monitoring (electrohystero-graphy and tocodynamometry) compared with internal monitoring with fetal scalp electrode and intrauterine pressure transducer. Reliability of external techniques was assessed by the success rate and positive percent agreement with internal methods. Bland–Altman analysis determined accuracy. We analyzed data from that study according to maternal body mass index. Main outcome measures We assessed the relationship between body mass index and monitor performance with linear regression, using body mass index as the independent variable and measures of reliability and accuracy as dependent variables. Results There was no significant association between maternal body mass index and any measure of reliability or accuracy for abdominal fetal electrocardiogram. By contrast, the overall positive percent agreement for Doppler ultrasound declined (p = 0.042), and the root mean square error from the Bland–Altman analysis increased in the first stage (p = 0.029) with increasing body mass index. Uterine contraction recordings from electrohysterography and tocodynamometry showed no significant deterioration related to maternal body mass index. Conclusions Accuracy and reliability of fetal heart rate monitoring using abdominal fetal electrocardiogram was unaffected by maternal obesity, whereas performance of ultrasound degraded directly with maternal size. Both electrohysterography and tocodynamometry were unperturbed by obesity.

Effect of diet- and lifestyle-based metabolic risk-modifying interventions on preeclampsia: a meta-analysis.

Abstract: Objective To evaluate the effect of dietary and lifestyle interventions with the potential to modify metabolic risk factors on the risk of preeclampsia. Data sources We searched MEDLINE, EMBASE and Cochrane from inception until February 2013. Randomized trials in pregnant women evaluating the effect of dietary and lifestyle interventions with the potential to modify metabolic risks such as obesity, hyperlipidemia, hyperglycemia and hypertension on the risk of preeclampsia were included. Study selection Two independent reviewers selected studies, extracted data and assessed quality. Results were summarized as pooled relative risks (RR) for dichotomous data. Results Eighteen studies (8712 women) met our search criteria for inclusion. Six studies evaluated diet (2695 women), six studied mixed interventions with diet, physical activity and lifestyle (1438 women) and six assessed essential fatty acid supplementation (4579 women). The interventions overall reduced the risk of preeclampsia (RR 0.81, 95% CI 0.69-0.94; p = 0.006 I(2) = 0%) compared with the control group. Dietary interventions reduced the risk of preeclampsia by 33% (RR 0.67, 95% CI 0.53-0.85; p = 0.001; I(2) = 0%). There was no reduction in the risk of preeclampsia with mixed interventions (RR 0.93, 95% CI 0.66-1.32, p = 0.68, I(2) = 0%) or fatty acid supplementation (RR 0.92, 95% CI 0.71-1.18; p = 0.49, I(2) = 15%). Meta-regression showed a borderline impact of gestational diabetes status (p = 0.05) on the observed effect. Conclusion Dietary and lifestyle interventions have the potential to reduce the risk of preeclampsia. The effect of additional therapeutic interventions in women with gestational diabetes mellitus on preeclampsia is not known.

Helping mothers survive bleeding after birth: an evaluation of simulation-based training in a low-resource setting

Abstract: Objective. To evaluate “Helping Mothers Survive Bleeding After Birth” (HMS BAB) simulation-based training in a low-resource setting. Design. Educational intervention study. Setting. Rural referral hospital in Northern Tanzania. Population. Clinicians, nurse-midwives, medical attendants, and ambulance drivers involved in maternity care. Methods. In March 2012, health care workers were trained in HMS BAB, a half-day simulation-based training, using a trainthe-trainer model. The training focused on basic delivery care, active management of third stage of labor, and treatment of postpartum hemorrhage, including bimanual uterine compression. Main outcome measures. Evaluation questionnaires provided information on course perception. Knowledge, skills, and confidence of facilitators and learners were tested before and after training. Results. Four master trainers trained eight local facilitators, who subsequently trained 89 learners. After training, all facilitators passed the knowledge test, but pass rates for the skills test were low (29% pass rate for basic delivery and 0% pass rate for management of postpartum hemorrhage). Evaluation revealed that HMS BAB training was considered acceptable and feasible, although more time should be allocated for training, and teaching materials should be translated into the local language. Knowledge, skills, and confidence of learners increased significantly immediately after training. However, overall pass rates for skills tests of learners after training were low (3% pass rate for basic delivery and management of postpartum hemorrhage). Conclusions. The HMS BAB simulation-based training has potential to contribute to education of health care providers. We recommend a full day of training and validation of the facilitators to improve the training.

Genetic, nongenetic and epigenetic risk determinants in developmental programming of type 2 diabetes

Abstract: Low birthweight (LBW) individuals and offspring of women with gestational diabetes mellitus (GDM) exhibit increased risk of developing type 2 diabetes (T2D) and associated cardiometabolic traits in adulthood, which for both groups may be mediated by adverse events and developmental changes in fetal life. T2D is a multifactorial disease occurring as a result of complicated interplay between genetic and both prenatal and postnatal nongenetic factors, and it remains unknown to what extent the increased risk of T2D associated with LBW or GDM in the mother may be due to, or confounded by, genetic factors. Indeed, it has been shown that genetic changes influencing risk of diabetes may also be associated with reduced fetal growth as a result of reduced insulin secretion and/or action. Similarly, increased risk of T2D among offspring could be explained by T2D susceptibility genes shared between the mother and her offspring. Epigenetic mechanisms may explain the link between factors operating in fetal life and later risk of developing T2D, but so far convincing evidence is lacking for epigenetic changes as a prime and direct cause of T2D. This review addresses recent literature on the early origins of adult disease hypothesis, with a special emphasis on the role of genetic compared with nongenetic and epigenetic risk determinants and disease mechanisms.

Epigenetics as the mediator of fetal programming of adult onset disease: what is the evidence?

Abstract: The Developmental Origins of Health and Disease hypothesis describes how early life environmental factors influence development in a way that impacts later health and disease risk. The hypothesis is supported by a large number of animal studies and a smaller number of observational studies in humans. Epigenetic variation induced in early life has emerged as a prime candidate to be the mediator of such effects, but little direct evidence of this relation exists in humans, primarily due to the inherent problems associated with unraveling the relative contributions of genetic and environmental variables to phenotypic diversity. There are several prerequisites for establishing a causal link that include demonstrating interindividual epigenetic variability in early life in response to specific environmental exposures. Further, compelling evidence linking epigenetic change to disease, prior to onset is required. Finally, the functional relevance of specific epigenetic change must be demonstrated. Evidence is emerging in all of these areas but, ultimately, only large longitudinal life-course studies, commencing prior to birth, can provide direct evidence in support of a role of epigenetic processes as a driver of Developmental Origins of Health and Disease in humans.

Causes of stillbirth at different gestational ages in singleton pregnancies.

Abstract: Objective To compare causes of stillbirth in preterm and term pregnancies. Design Cohort study. Setting All delivery wards in Stockholm, 1998–2009. Population Stillbirths from singleton pregnancies of gestational age ≥22+0 (n = 1089) extracted from a web-based database including all stillbirths in the major Stockholm area since 1998. Methods The parents of the stillborns were all offered an extensive standardized investigation. The causes of death were assigned in a perinatal audit using the Stockholm classification of stillbirth. Singleton stillbirths were divided into preterm (gestational week 22+0–36+6) and term/post-term (gestational week ≥37+0). The term/post-term group was subdivided into term (gestational week 37+0–40+6) and post-term stillbirths (gestational week ≥41+0). Main outcome measure Causes of stillbirth at different gestational ages. Results A higher proportion of placental abruption and preeclampsia/hypertension was seen in preterm stillbirths compared with term/post-term stillbirths, which instead had a higher proportion of umbilical cord complications and infection. Infection was more common in post-term than term stillbirths (46.5 vs. 19.8%, p < 0.001). Conclusion Increased knowledge of causes of stillbirth in different gestational ages may be valuable in developing strategies for prevention of fetal death. The high proportion of infection in post-term stillbirths could be clinically important and warrants further studies.