Acta Obstetricia Et Gynecologica Scandinavica

The size of the labor ward: is bigger better when it comes to patient safety? This headline of an article published by Milland, Christoffersen and Hedegaard (1) promises an answer, but the article provides neither data nor an analysis capable of answering this question as patient claims, which are the data in this analysis, are random and a surrogate measure for patient safety. Such data are not in themselves strong enough to justify organizational changes. Based on an analysis of 1326 claims/991 375 births submitted in 1995-2009, the authors conclude that there is a significant difference between number of claims and the size of a labor ward. This article is protected by copyright. All rights reserved.

To test the hypothesis that clinically relevant vessels can be visualized and interrogated with Doppler recording during the second half of pregnancy at an output energy below the currently advocated limits without loss of information. Observational cross-sectional study. Tertiary fetal medicine center. Based on a power calculation for equivalence studies, we recruited 65 pregnant women. Ultrasound examination was performed at 18, 24 or 36 weeks of gestation. The umbilical artery, middle cerebral artery, ductus venosus, and both uterine arteries were identified using color Doppler, and the blood velocities were measured using pulsed wave Doppler at a thermal index for bone (TIB) of 1.0. This procedure was repeated at TIB values of 0.5 and 0.1. The depth of Doppler recording was noted. Visualization of the vessels by color Doppler at all power levels and any systematic changes or increased variance of the recorded parameters with decreasing power level. All vessels could be visualized by color Doppler and their flow velocities measured using pulsed wave Doppler in all participants and at all power levels. There were no systematic changes or increased parameter variance when reducing the power level, despite the insonation depth being significantly greater than in early pregnancy. Reducing the ultrasound power from TIB 1.0 to 0.1 does not alter color Doppler visualization or pulsed wave Doppler measurements in the second half of pregnancy. The lower power level can be recommended as a starting point for clinical examinations throughout pregnancy.

To study whether paracervical block (PCB) with 12.5 mg (0.125%) of bupivacaine is as effective as with 25 mg (0.25%) and if there are differences in fetal heart rate (FHR) patterns between the doses. A prospective, randomized double-blind study. Fifty-two patients received PCB with 25 mg and 45 patients with 12.5 mg of bupivacaine. Pain intensity was assessed by the patients on a horizontal visual analog scale (VAS). Fetal heart rates of the fetuses were analyzed visually concerning basal rate, variability, accelerations, bradycardia, silent pattern and decelerations. The pain relief was statistically significant in both groups up to 120 min after PCB. The VAS-values were similar in both groups both before and after PCB. Fetal heart rate changes appeared in both groups more frequently after than prior to PCB. In patients receiving 25 mg of bupivacaine there appeared to be more FHR changes than in those receiving 12.5 mg. Paracervical block with 12.5 mg of bupivacaine is an effective method to relieve pain during labor. Fetal heart rate changes seemed to appear less frequently with this reduced dose. It seems that by lowering the dose of bupivacaine it is possible to reduce fetal side-effects without losing analgesic effect.

The objective of the study was to evaluate and compare the safety of levobupivacaine and racemic bupivacaine for paracervical block (PCB) in the first stage of labor after uncomplicated pregnancy. Forty women in an open pilot study and 397 women in a double-blind randomized study received PCB for pain relief in the first stage of labor, either with 25 mg of levobupivacaine or with 25 mg of racemic bupivacaine. The incidence of cardiotocographic pathology was compared between the groups using Fisher's exact test. The 95% confidence intervals for the between-group difference were calculated by Newcombe's method. In the randomized double-blind study, the incidence of any pathological result in cardiotocography (CTG) was 10.4% in the levobupivacaine group and 12.8% in the racemic bupivacaine group. The incidence of fetal bradycardia in the groups was 2.6 and 3.8%, respectively. All the cardiotocographic changes were transient, and no operative intervention was indicated because of CTG. No difference in the analgesic effect between the drugs was found. Most of the parturients in the levobupivacaine group (97%) and in the racemic bupivacaine group (96%) had spontaneous vaginal delivery. Neonatal outcome was good in both groups. No difference in cardiotocographic pathology was found between PCB with levobupivacaine compared with PCB with racemic bupivacaine. The incidence of bradycardia was low. PCB was found to be a safe pain-relief method for low-risk parturients.

To determine the dose of acetylsalicylic acid (ASA), that inhibits the production of the vasoconstrictive, aggregatory thromboxane A2 while sparing the production of the vasodilatory antiaggregatory prostacyclin. A controlled study comparing the effects of three doses of ASA on the production of thromboxane A2 and prostacyclin. Seven pregnant hypertensive patients and five non-pregnant healthy women received 0.5, 1.0 and 2.0 mg/kg/day of ASA, each dose for 10-12 days, the treatment periods following each other immediately. Seven normotensive pregnant women served as controls and were given no ASA. Blood and urine samples were taken at baseline and after the treatment periods to determine serum thromboxane B2 and the urinary 2.3-dinor-6-ketoprostaglandin F1alpha and 11-dehydrothromboxaneB2, the major stable metabolites of prostacyclin and thromboxane A2, respectively. The urinary excretion of 11-dehydrothromboxaneB2 was significantly higher in both hypertensive (34.9+/-18.3 pg/micromol creatinine) and normotensive (39.3+/-14.4 pg/micromol creatinine) pregnant women than in non-pregnant women (14.8+/-6.4 pg/micromol creatinine). The urinary excretion of 2.3-dinor-6-ketoprostaglandinF1alpha was also higher in normotensive pregnant women (93.9+/-50.9 pg/micromol creatinine) than in non-pregnant women (18.2+/-11.3 pg/micromol creatinine). The excretion rate of 2.3-dinor-6-ketoprostaglandinF1alpha in hypertensive patients was lower than in normotensive pregnant women (44.7+/-24.2 pg/micromol creatinine). At baseline the urinary 2.3-dinor-6-ketoprostaglandin F1alpha/11-dehydrothromboxaneB2 ratio was almost the same in the hypertensive patients (1.6) and in the non-pregnant women (1.2). The ratio was 2.6 in normotensive pregnant women. In the hypertensive group, already the lowest dose of ASA inhibited urinary 11-dehydrothromboxaneB2 excretion significantly. Because none of the doses of ASA inhibited 2.3-dinor-6-ketoprostaglandinF1alpha production, the 2.3-dinor-6-ketoprostaglandinF1alpha/11-dehydrothromboxaneB2 ratio was shifted in the favor of prostacyclin at all dose levels. In the non-pregnant women, even the highest dose level of ASA failed to affect the ratio. In the dose range of 0.5-2.0 mg/kg/day, ASA has a favorable effect on the ratio of prostacyclin to thromboxane A2 in hypertensive pregnancies.

Earlier studies have shown that ampicillin produces 50% lower-and therefore very likely less adequate-plasma levels in pregnant than in nonpregnant women. The present investigation compares levels of ampicillin in plasma and urine produced by a single oral dose administered to 10 healthy women taking oral contraceptives on the 21st and on the 28th day of the menstruation cycle. Plasma levels of ampicillin were lower on the 21st day than on the 28th, i.e. a difference in the same direction as between pregnant and nonpregnant women although the difference was not significant. Contrary to what was found for pregnant women the dose of ampicillin to women taking oral contraceptives does not have to be doubled in order to compensate for lower plasma levels. PIP Because in pregnant women administration of ampicillin produces plasma levels of about 50% those reached in these same women when they are not pregnant and because oral contraceptive use causes a pregnancy-like condition, a study was conducted to investigate the effect of oral contraceptive use on plasma and urine levels of ampicillin. A single oral dose of .5 gm ampicillin was administered to 10 healthy oral contraceptive users on the 21st and 28th days of their cycles (8 used levonogestrel .25 mg, ethinyl estradiol .05 mg; 1 used levonogestrel .5 mg, ethinyl estradiol .05 mg; and 1 used lynestrenol 2.5 mg, ethinyl estradiol .05 mg). It was found that plasma levels were lower on the 21st day at 1, 2, 3, and 8 hours than on the 28th day with a significant dfference occurring only at 1 hour. Mean values for peak level, ACU, CIR 0-8 hours, and recovery in urine were also lower on the 21st day, but not significantly. Although this trend is the same as that seen in pregnant versus not pregnant women, the plasma levels of ampicillin on the 21st day compared well with levels found in nonpregnant women. Therefore, no further investigation is warranted.

Objective: To investigate the risk for anal sphincter tears (AST) in infibulated women. Design: Population-based cohort study. Setting: Nationwide study in Sweden. Population: The study population included 250 491 primiparous women with a vaginal singleton birth at 37-41 completed gestational weeks during 1999-2008. We only included women born in Sweden and in Africa. The African women were categorized into three groups; a Somalia group, n = 929, where over 95% are infibulated; the Eritrea-Ethiopia-Sudan group, n = 955, where the majority are infibulated, compared with other African countries, n = 1035, where few individuals are infibulated but had otherwise similar anthropometric characteristics. These women were compared with 247 572 Swedish-born women. Methods: Register study with data from the National Medical Birth Registry. Main outcome measures: AST in non-instrumental and instrumental vaginal delivery. Results: Compared with Swedish-born women, women from Somalia had the highest odds ratio for AST in all vaginal deliveries: 2.72 (95%CI 2.08-3.54), followed by women from Eritrea-Ethiopia-Sudan 1.80 (1.41-2.32) and other African countries 1.23 (0.89-1.53) after adjustment for major risk factors. Mediolateral episiotomy was associated with a reduced risk of AST in instrumental deliveries. Conclusion: Delivering African women from countries where infibulation is common carries an increased risk of AST compared with Swedish-born women, despite delivering in a highly technical quality healthcare setting. AST can cause anal incontinence and it is important to investigate risk factors for this and try to improve clinical routines during delivery to reduce the incidence of this complication.

Sexual behavior is of public health interest because of the association with reproductive health and sexually transmitted infections such as human papillomavirus, which is the causal factor of cervical cancer. The aim of the study was to describe patterns in women's sexual behavior in four Nordic countries. Population-based cross-sectional study. Denmark, Iceland, Norway, and Sweden (November 2004-June 2005). A random sample of 18-45-year-old women from the female population in the four participating Nordic countries. The participation rate ranged from 81.3% in Denmark to 54.5% in Iceland. In total, 65 623 women were included. Each participant completed a structured questionnaire containing questions about sociodemographic factors, lifestyle factors and sexual behavior. Age-specific and country-specific descriptive measures of sexual behavior, notably age at first intercourse and lifetime number of partners. In addition, risk factors for having had multiple (>10) sexual partners were examined. Overall, median age at first intercourse was 16, and 30.2% (95% CI: 29.9-30.6) of the participating women reported having had ≥10 partners. There was great variation with birth cohort but limited variation between countries. The main correlates of multiple sexual partners were increasing age at enrollment, a higher alcohol intake and young age at first intercourse. These measurements of sexual behavior before the introduction of national human papillomavirus vaccination programs will form the basis for a comparison with a similar survey performed after vaccination has been introduced.

Maternal serum alphafetoprotein (MSAFP) screening has been set up in Asturias, in the north of Spain, in 1987 in order to make possible the prenatal diagnosis of neural tube defects (NTD) to overall pregnancy population. This large study shows the high sensitivity and specificity of MSAFP screening when it is done with absolute control of all variables such as gestational age, pregnant woman's weight, diabetes, etc. On the other hand, this study also shows a poor sensitivity second level ultrasound for the early diagnosis of NTD in the presence of spina bifidas with no bulge. We have also observed that the incidence of NTD in Asturias remained constant in the last six years, around 1.5-1.6 per 1000 pregnancies. However, due to MSAFP screening, there has been a decline in the prevalence of children born with these defects. We conclude that MSAFP screening is the best tool to identify and reduce NTD in our Region (Spain).

To systematically review the risks of pregnancy outcomes among women of different parity. Electronic databases were searched for studies, in English language, in which primary objective was to assess association between parity and pregnancy outcomes. Meta-analyses were performed and unadjusted odds ratios (ORs) and mean differences along with 95% confidence interval (CI) were calculated. Low birth weight (LBW), preterm birth (PTB), small for gestational age (SGA), birth weight, and gestational age. Forty-one studies, most with moderate risk of bias were included. Nulliparity was associated with increased unadjusted odds of LBW (OR 1.41, 95% CI 1.26, 1.58) and SGA (OR 1.89, 95% CI 1.82, 1.96) and reduction in birth weight (weighted mean difference -282 g, 95% CI -486, -79 g) but not PTB (OR 1.13, 95% CI 0.96, 1.34). Grand multiparity and great grand multiparity were not associated with LBW (OR 1.10, 95% CI 0.95, 1.32 and OR 0.92, 95% CI 0.78, 1.09) or PTB (OR 0.96, 95% CI 0.77, 1.19 and OR 1.32, 95% CI 0.61, 2.83). Nulliparity was associated with a significantly increased unadjusted risk of LBW/SGA birth, whereas grand multiparity and great grand multiparity were not associated with increased risk of pregnancy outcomes.

During a 2 1/2-year period, 1 056 pregnant women (1 072 fetuses) were monitored with the nonstress test (NST) in the antenatal period. Testing time was 30 minutes. The NST was classified into one of four classes: normal, suspect pathological, slight pathological, and severe pathological. In 88.5% of the pregnancies, all NSTs were normal. Suspect, slight, or severe pathological NSTs occurred at least once in 8.1%, 2.1%, and 1.3% of the women respectively. All women with a severe pathological NST had high-risk complications. Lethal malformations excluded, there were only two perinatal deaths among the tested women. In the four different classes, the frequencies of cesarean section were 11%, 17%, 41%, and 79%. One-minute Apgar scores were less than 7 in 5%, 12%, 41%, and 64%. The need for referral to neonatal intensive care was 19%, 40%, 41%, and 93% respectively. A normal NST predicted normal fetal outcome in an excellent way, while the three pathological classes appeared to represent different degrees of impending fetal jeopardy.

The objective of this study was to determine whether the circulatory levels of endothelins, potent vasoconstrictor polypeptides produced mainly by endothelial cells, are increased in growth-retarded fetuses. Fetal venous serum samples, withdrawn by ultrasound-guided cordocentesis from 11 growth-retarded fetuses and 10 normally-growing fetuses who underwent the procedure because of other unrelated indications, were examined for immunoreactive endothelin-1,2 by radioimmunoassay. Higher mean endothelin-1,2 levels were found in the sera of growth-retarded fetuses than in controls (16.8 +/- 4.2 versus 10.9 +/- 4.3 fmol/ml, p = 0.008). Within the growth-retarded group, there were no differences in endothelin-1,2 levels in the presence of either abnormal umbilical Doppler, asymmetry of growth-retardation, maternal signs of preeclampsia, or fetal acidosis. High levels of endothelin-1,2 in the fetoplacental circulation may be pathophysiologically important in fetal growth retardation. However, the clinical significance of these elevated levels is yet to be determined.

The pathogenesis of intrahepatic cholestasis of pregnancy (ICP) involves impaired bile acid and estrogen/progesterone metabolism and excretion based on genetic and environmental factors. The role of vitamin D is undefined. Observational study. Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden. Swedish. We measured serum 1,25-dihydroxy vitamin D3 (1,25-D3) and parathormone in 22 women with ICP at presentation, in comparison with 11 healthy women at delivery. ICP women had significantly (p = 0.0041) lower levels of 1,25-D3 in serum (76.4 ± 23.1 vs. 112.0 ± 40 ng/L, mean ± SD), unrelated to serum bile acids. 1,25-D3 levels were inversely correlated (p < 0.05) to meconium staining of amniotic fluid. Parathormone levels did not differ between ICP and healthy women. Lower 1,25-D3 levels in ICP are inversely correlated by meconium staining, a major indicator of fetal distress. Our finding may have pathogenetic and clinical implications since vitamin D regulates steroid metabolism and 1,25-D3 deficiency may impair fetal outcome.

In 25 normally non-pregnant women, 543 normally pregnant women and 75 pregnant women with diabetes mellitus or gestational diabetes mellitus, the relationship between the serum concentration of 1,5-anhydro-D-glucitol (1-deoxy-glucose) and carbohydrate metabolism was studied. The concentration of 1,5-anhydro-D-glucitol was estimated by means of gas-liquid chromatography. In normally non-pregnant women the concentration was found to be 18.6 +/- 5.2 mg/l (mean +/- SD). During the normal pregnancy, from 9 weeks of gestation, a steadily decreasing concentration was observed as the pregnancy progressed and the lowest value (10.2 +/- 4.6 mg/l) was found in the third trimester. After 5 days of puerperium the concentrations were found to be 10.8 +/- 3.7 mg/l. On the 30th day postpartum, the level was within the range for non-pregnant subjects. The values in pregnant women with diabetes mellitus and gestational diabetes mellitus were mostly below 10 mg/l throughout the entire pregnant period. The 1,5-anhydro-D-glucitol concentration was not affected by meals or oral glucose loading. A concentration below 10 mg/l was found in 36% of the normally pregnant women, where oral glucose tolerance tests and measurement of glycohemoglobin were shown to be within the normal range. The present study suggests that a change of 1,5-anhydro-D-glucitol level during pregnancy may reflect a mild alteration of carbohydrate metabolism that goes undetected by all the other diabetic indicators.

To investigate the frequency of the interleukin-10 (IL-10)-1082 G/A single nucleotide polymorphism in women with intrauterine fetal death (IUFD), pre-eclampsia (PE), preterm delivery (PD), and small for gestational age (SGA) infants. In a prospective cohort study, DNA from 1,616 consecutive pregnant women was analyzed for IL-10 -1082 G/A by polymerase chain reaction. Women who developed at least one of the predefined pregnancy complications were used as cases and compared to women without pregnancy complications. Of 1,616 women, 254 (15.7%) developed at least one pregnancy complication. IL-10 -1082 G/A allele frequencies (G: 233/508 [45.9%] and A: 275/508 [54.1%] versus G: 1,143/2,724 [42.0%] and A: 1,581/2,724 [58.0%], respectively; p=0.10; OR 0.85; 95% CI 0.69-1.04) and genotype distributions (A/A+G/A: 201/254 [79.1%] and G/G 53/254 [20.9%] versus A/A+G/A: 1,125/1,362 [82.6%] and G/G 237/1,362 [17.4%], respectively, p=0.19; OR 0.79; 95% CI 0.54-1.15) were not significantly different between cases and controls. We observed no statistically significant difference in IL-10 -1082 G/A genotype distribution comparing controls and women with IUFD, PE, PD <37 weeks gestation, and SGA infants (<10th percentile). IL-10 -1082 G/A polymorphism is not a genetic marker for identifying women at increased risk of common pregnancy complications.

Infertility is a severe, stressful experience. Sense of coherence (SOC) is an individual attribute which reflects the ability to resist severe strain. According to Antonovsky, SOC is stable throughout adulthood, but there is little empirical evidence to support this. In a prospective study, we focused on 2 research questions: (i) Does childbirth after assisted reproductive technology (ART) result in high SOC? (ii) Does the level of SOC at baseline influence the association between childbirth after ART and SOC at 1-year follow-up? The study included a consecutive sample of patients in ART from a prospective, longitudinal survey in Denmark; baseline response rate 80.0%, 1-year follow-up 87.7% (n=1,934). The dependent variable was SOC at 1-year follow-up measured by Setterlind's 9-item scale. The independent variable was having achieved childbirth after ART. Data were analysed by logistic regression analysis adjusted for baseline SOC. Having achieved childbirth after ART was associated with higher SOC at 1-year follow-up (women OR=1.81,95% CI: 1.202.74; men OR=1.27, 95% CI: 0.881 − 86). Unexpectedly, the association between achieving childbirth after ART and high SOC at 1-year follow-up was significant among women who had low SOC at baseline. There was no association among participants with high SOC at baseline. The study indicated that SOC is not necessarily stable throughout adulthood, since a successful outcome of ART among women was associated with a significant increase in SOC.

Twin pregnancies constitute 25% of all in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) pregnancies. There is a lack of knowledge on maternal risks and perinatal outcome of IVF/ICSI twin pregnancies. National survey by questionnaire (n = 1769). The study population consisted of all IVF/ICSI twin mothers (n = 266) and the two control groups of all IVF/ICSI singleton mothers (n = 764) and non-IVF/ICSI twin mothers (n = 739) who delivered in Denmark in 1997. The response rate was 89% among IVF twin mothers and overall 81%. In terms of maternal risks and perinatal outcome no significant differences were observed between IVF/ICSI twin and non-IVF/ICSI twin pregnancies after stratification for maternal age and parity. Nevertheless, IVF/ICSI twin mothers were more frequently on sick leave (OR 2.5, 95% CI 1.5-4.0) and hospitalized (OR 1.9, 95% CI 1.3-2.8) during pregnancy. Compared with IVF/ICSI singleton pregnancies, IVF/ICSI twin pregnancies were characterized by a higher incidence of preeclampsia (OR 2.4, 95% CI 1.5-4.2) and a higher frequency of sick leave (OR 6.8, 95% CI 4.4-10.5) and hospitalizations during pregnancy (OR 3.5, (95% CI 2.5-4.9); moreover, mean birthweight (p < 0.001) and gestational age (p < 0.001) were lower. No differences were observed in the incidence of pregnancy-induced hypertension and gestational diabetes between IVF/ICSI twin and singleton pregnancies. Although this population study indicates that maternal risks in IVF/ICSI twin pregnancies are comparable with non-IVF/ICSI twin pregnancies, the IVF/ICSI twin mothers were more likely to be on sick leave or hospitalized during pregnancy. Furthermore, maternal risks were higher and obstetric outcome poorer in IVF/ICSI twin vs. IVF/ICSI singleton pregnancies.

During the 1970s, surgery undertaken to remedy infertility at Sabbatsberg Hospital in Stockholm involved macrosurgical techniques. The patients described here had the same pathology on either side. Sixty-three underwent different procedures for the correction of tubal pathology at laparotomy, while 20 patients had lysis of adhesions performed at laparoscopy. A further 18 patients were operated on for ovarian endometriosis. The results in terms of conceptions (ranging from 43 to 60%, depending upon the type of operation) were similar to those reported from microsurgery, but the incidence of ectopic pregnancy was higher. Second-look laparoscopy revealed the presence of adhesions and tubal block in a significant number of patients, though less often in those who ultimatively conceived. There was no difference in semen findings between patients who conceived and those who did not. Postoperative adhesions are responsible for many surgical failures, but refined methods of surgery may reduce the risk of future ectopic gestation. Only a limited number of cases remain where persistence of infertility may be due to minor anatomical or functional defects not amenable to present-day clinical evaluation.

A report is given of the results of tubal surgery in 101 cases selected from 851 sterility patients. The follow-up time was 3-10 years. Ordinary surgical technique was applied with the use of prednisolone and antibiotics but largely without the use of polyethylene tubing or other splints. Fourteen surgeons were involved. Since the most experienced surgeon operated on about 30% of the cases, an assessment of the effect of the surgeon's skill was possible. The patients are divided into groups with regard to type of operation, and the result is judged with regard to conception, live birth, ectopic pregnancy and abortion as well as with regard to patency. After salpingolysis the conception rate was 52%, and after salpingostomy 32%. There was, however, a gap between the conception rate and the live birth rate, especially for the salpingostomy cases. The live birth rate was more than twice as high after salpingolysis than after salpingostomy. The small lasting effect of cut adhesions is also demonstrated by the observation that combined unilateral or bilateral lysis did not interfere with the result after salpingostomy. Contrary to this, the patients conceived faster after salpingostomy than after salpingolysis. There was no difference between the results in the patients operated on by the most experienced surgeon and in those treated by the thirteen less skilled gynecologists.

To investigate the prenatal course and functional outcome for fetuses with spina bifida according to the level of the spinal lesion at prenatal ultrasound examination. Retrospective, descriptive study. Tertiary referral center, Germany. A total of 103 fetuses with spina bifida identified between 1993 and 2008. The antenatal course and postnatal outcome for affected fetuses were reviewed. The relation of relevant outcome domains to the anatomical level was assessed using Fisher's exact test and the χ(2)-test. Level and type of spinal lesion, pregnancy outcome, psychomotor development, bladder and bowel function. Our cohort included a total of 31 live born infants, 68 terminated pregnancies, four intrauterine fetal deaths and five postnatal deaths. Four cases were excluded from follow-up. Twenty of the remaining 22 infants had normal or only slightly impaired mental development (91%). Thirteen children (59%) were able to walk, but nine (41%) needed wheelchairs or were paraplegic. The rate of poor motor outcome varied strongly in dependence on the level of the lesion (22.2% at lower lumbosacral levels to 80% at thoracic level). The majority of the affected children (16/22, 72.7%) suffered from impairment of bladder function. In 36% of cases (8/22) anal incontinence was documented. Spina bifida can result in a spectrum of disabilities that frequently lead to an impairment of bladder, bowel and motor function. The motor function depended on level of the lesion.

To survey the accuracy of fetal gender determination during first trimester screening and scan for congenital anomalies. A prospective observational study was performed on 496 singleton pregnancies at the first trimester ultrasound screening. The doctor was a certified sonographer of first trimester screening by the Fetal Medicine Foundation(FMF). Ultrasound examination was performed on a GE Voluson 730 Pro, transabdominally, between 11 and 13(+6) weeks. Both transverse and mid-sagittal planes of a section of the fetal genital tubercle were performed to identify the gender. The subsequent gender at birth was obtained from karyotyping reports or hospital birth records. During the study, 496 patients requested gender information at the time of first trimester screening. Of the patients it was possible to determine gender (441 out of 496), the scan achieved an overall success rate of 91.8% in correctly identifying gender. The success rate for correctly identifying fetal gender (where identification was possible) increased with gestational age, from 71.9% at 11 weeks, 92% at 12 weeks, and 98.3% at 13 weeks, respectively, where gestational age was calculated from the crown-rump length in conjunction with menstrual or ovulation dating (p<0.001). Of the 55 cases where no identification of gender was possible, 39 were in the 11-week gestational age group, representing 40.6% of this category. The overall fetal gender accuracy rate for male fetus was slightly better than female (92.5 versus 91.2%), but was not statistically significant. This study demonstrated that the gestational age of the fetus has a material effect on the accuracy rate of gender determination. At 12 weeks and over, the average success rate for correctly identifying gender, where gender identification was possible, was 94.8%, with the accuracy at 13 weeks of 98.3% approaching that achieved by invasive testing. Fetal gender identification at 11

The study objective was to determine the parental origin of triploidy in relation to findings from early risk assessment in a combined screening program between 2004 and the end of 2006. Triploidy was diagnosed in six chorion villus samples and two samples from missed abortions. After informed consent, quantitative fluorescence polymerase chain reaction analysis was performed on the five cases where we received blood from both parents and tissue from fetuses. In four cases the origin of the triploidy was paternal and in one maternal, in accordance with previous findings in type I and type II triploidies. Finding triploidy is possible by risk assessment (ultrasound and double test), and thereby women may have the opportunity for early termination of pregnancy.

To compare different three-dimensional (3D) methods in the assessment of gestational sac volume (GSV). Cross-sectional study involving 74 normal pregnancies between 7 and 11 weeks. Department of Obstetrics, São Paulo Federal University (UNIFESP). GSV was measured through 3D ultrasound using the planimetric, virtual organ computer-aided analysis (VOCAL) and extended imaging virtual organ computer-aided analysis (XI VOCAL) methods. The planimetric method used a sequence of adjacent planes that are 3 mm thick. For the VOCAL methods, six adjacent planes and a 30 degrees rotation were used. A total of 15 adjacent planes were used for the XI VOCAL method. Regression models with a determination coefficient (R(2)) were created to assess the correlation between GSV and gestational age (GA). Intraclass correlation coefficient (ICC) and Bland-Altman graphs were used to assess the correlation between the three methods and ANOVA was used to compare means. All three methods showed a correlation between GSV and GA (R(2) = 0.65 for XI VOCAL, R(2) = 0.65 for planimetric and R(2) = 0.66 for VOCAL). There was a strong correlation between the three methods (XI VOCAL vs. planimetric ICC = 0.995; XI VOCAL vs. VOCAL ICC = 0.998 and planimetric vs. VOCAL ICC = 0.995) without any significant differences according to the Bland-Altman graphs or ANOVA (p < 0.002). The three 3D ultrasound methods used for GSV assessment between 7 and 11 weeks are concordant. These methods can be used interchangeably during the first trimester of pregnancy to measure GSV.

Human papillomavirus (HPVs) types 6 and 11, are frequently found in non-malignant anogenital condylomas and laryngeal papillomas. However, in an ongoing epidemiological study in Argentina in which 163 anogenital and aero-respiratory cancer biopsies were analyzed, several cases infected with low-risk HPVs could be detected. Tumor samples were analyzed by Southern blot hybridization, using HPVs 6, 11, 16, 18, 30, 31, 33 and 35 as probes, and polymerase chain reaction (PCR) with type-specific primers and probes. Four invasive carcinomas containing HPV 6 or 11 could be detected (2.4%) by Southern blot technique. HPV 6 DNA was found in a penile carcinoma, a groin carcinoma, and in a tonsillar carcinoma. One cervical carcinoma harbored HPV 11 DNA. Using HPVs 6, 11, 16, 18 and 33 anticontamination primers and probes in PCR, no additional high-risk HPV types could be detected in these four cancers. This report shows the presence of low-risk HPVs (HPV 6 and 11) associated to malignant tumors in a frequency higher than usually observed. The data raise questions about which are the circumstances which may favor low-risk HPV related oncogenesis.

To assess the role of uterine artery Doppler studies at 11-14 weeks in screening for pre-eclampsia (PET), small for gestational age (SGA) fetuses, and placental abruption. Prospective study on 1,123 women presenting for routine ultrasound examination at 11-14 weeks for nuchal translucency measurement. Uterine artery blood flow was studied by transvaginal colour Doppler, the mean pulsatility index (PI) was calculated, and the presence of a diastolic notch was recorded. The mean, median and 95th centile of uterine artery PI were 1.71, 1.64 and 2.54, respectively. Bilateral notches were observed in 63.4%, and a unilateral notch in 18.4% of cases. The sensitivity of mean uterine artery PI>or=95th centile for PET, early onset severe PET necessitating delivery before 34 weeks, SGA<or=5th centile, SGA necessitating delivery before 34 weeks, SGA<or=10th centile and placental abruption were 21.4, 33.3, 17.8, 100, 9.6 and 44.4%, respectively. One in 6 women with increased resistance in the uterine arteries at 11-14 weeks will develop a complication related to utero-placental insufficiency. Abnormal uterine Dopplers at 11-14 weeks identified one-third of women with severe early onset pre-eclampsia, all fetuses with SGA<or=5th centile that were delivered at<or=34 weeks, and 40% of cases with placental abruption. Uterine artery Doppler examination at the 11-14 weeks scan can identify a high risk population in which preventive or therapeutic interventions might be effective.

By use of Positron Emission Tomography (PET), dynamic studies of the metabolism within the feto-maternal unit can be performed using various tracers. Many compounds like amino acids, carbohydrates, fatty acids and drugs can be performed using various tracers. Many compounds like amino acids, carbohydrates, fatty acids and drugs can be labelled with 11C and used as tracers. 11C-labelled L- or D-methionine was injected intravenously into pregnant Rhesus monkeys. The distribution of the radioactivity in maternal muscles, aorta, placenta and the liver of the fetus was quantitatively estimated as a function of time. Simultaneously blood, urine and amniotic fluid samples were analyzed for 11C-activity. The distribution of 11C between the high and the low molecular fraction of plasma (MW greater than 5000) was studied after gel filtration. Both when 11C-L- and D-methionine were given, the radioactivity rapidly crossed the placenta and was accumulated in the fetal liver. In the 11C-L-methionine experiments, about 70 per cent of the radioactivity in plasma was found in the high molecular fraction one hour after injection. A greater part of 11C-D-compared to 11C-L-activity was excreted in the urine.

The aim of the study was to estimate the cumulative incidence of venous thromboembolism during pregnancy and the puerperium. All diagnoses concerning venous thromboembolism in the Hospital Discharge Registry from a Danish County in women less than 49 years of age from 1984 to 1994 were included. The number of deliveries in the County during this period was obtained from The Medical Registry of Birth. The cumulative incidence of venous thromboembolism during pregnancy and puerperium was 0.85 (95% CI: 0.64-1.11) per 1000 deliveries. The cumulative incidence was 0.49 (95% CI: 0.28-04).80) in 1984-89 but increased to 1.23 (95% CI: 0.87-1.69) after the introduction of ultrasound. The risk of diagnosed venous thromboembolism is low but estimates of the incidence are probably procedure dependent.

This study was planned to evaluate the efficiency of the 11-14 week scan in detecting fetuses with major fetal structural abnormalities. Some 1,290 pregnant women were submitted to a routine ultrasound scan between the 11th and 14th week after the detection of the fetal viability. The fetal anatomy was examined transabdominally, and in suspected cases transvaginally. Following the scans, the patients were examined in the second or third trimester of pregnancy. Fetal structural abnormalities classified as major and early onset were noted. Isolated choroid plexus cysts, cardiac defects not requiring treatment, mild ventriculomegaly, and mild renal pelviectasis in second trimester were not included. Twenty-four (1.86%) fetuses with various defects were identified, and 17 of these were diagnosed at the 11-14 week scan. The antenatal ultrasound detection rate of the fetuses with major anomalies was 95%, and 70% were detected in the first-trimester assessment. Four cardiac defects associated with genetic syndromes or requiring operation were included (0.31%) in this series. Two of the fetuses with cardiac defects (50%) had an increased nuchal translucency thickness. In this group, none of the fetuses with karyotype anomalies was born alive. The first-trimester scan is important in routine antenatal care for early detection of fetal defects, and determination of the fetuses at risk of cardiac anomalies and genetic syndromes.

To generate a regression equation for the nuchal translucency (NT) median for the Swedish population and compare this with other median values. Eight Swedish hospitals. The data set included 20 887 unaffected fetuses. Calculation and generation of an NT centile chart for the Swedish population. The NT centiles for crown-rump length (CRL) from 45 to 84 mm were calculated and compared with the medians from Glasgow, from the Fetal Medicine Foundation (FMF, London, UK; FMF-original) and those published recently (FMF-new). The NT medians cease to increase at CRLs between 70 and 75 mm. The Swedish, FMF-new and Glasgow medians followed the same pattern, but the Glasgow NT median curve was systematically lower by around 20%. Swedish, FMF-new and Glasgow medians differed in shape from the FMF-original medians, which continuously increase throughout the whole range of CRLs. Our results demonstrate that there are substantial differences in the NT medians and centiles between countries.

Long-term efficacy evaluations of a quadrivalent HPV type 6/11/16/18 vaccine are ongoing in the Nordic region. As there are limited epidemiological data on HPV infection in Norway, we determined prevalence and identified sociobehavioural correlates of HPV 6/11/16/18 infection in young Norwegian women. Norwegian (n=898) women, aged 1624 years, were enrolled in a 4-year prospective study. At enrolment and at 6-month intervals thereafter, an interview on behavioural data and a gynaecological examination were undertaken. Genital samples were tested for the L1,E6 and E7 genes of HPV-6/11/16/18, and serum anti-HPV-6/11/16/18 levels were measured using a competitive Luminex immunoassay (cLIA). Results. DNA and seroprevalence of HPV 6, 11, 16 or 18 ranged from 0.9 to 16.3% and 2.6 to 16.2%,respectively; and most infected women (approximately 75%) were infected with only 1 type. Of the HPV DNA positive cases, 54.3, 50.0,47.3 and 38.5% had detectable HPV 6, 11, 16 or 18 antibodies, respectively. More than 50% of the high-grade cervical intraepithelial neoplasia (CIN) cases were HPV-16 or HPV-18 DNA positive. Lifetime number of partners was the strongest and only predictor of sero- and DNA-positivity across the 4 HPV types. Given the high prevalence of HPV infection among young women with mostly single-type infection, and the fact that type-specific HPV screening is not recommended prior to the administration of the quadrivalent HPV vaccine, our data suggest the importance of widespread,rather than targeted, immunisation.

The terrorist explosions of the World Trade Center in New York City and the other events on the Pentagon and in Pennsylvania on 11 September 2001 were stressful events that affected people around the world. Pregnant women and their offspring are especially vulnerable during and after such a terrorist attack. The objective was to systematically review the risks of adverse pregnancy outcomes after the terrorist attacks on Sept 11, 2001. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) criteria were used for reporting of this review. Statistical analyses were performed using RevMan 5.0. Ten reports of low-to-moderate risk of methodological bias were included. There was increased risks of infants with birthweight of 1,500 g-1,999 g (adjusted odds ratio [AOR] 1.67 [95%CI 1.11-2.52]) and small-for-gestational age births (AOR 1.90; 95%CI 1.05-3.46) in New York. There was increased risks of low birthweight (relative risk 2.25; 95%CI 1.29-3.90) and preterm births (relative risk 1.50; 95%CI 1.06-2.14) among ethnically Arabic women living in California There was a reduction in birthweight by 276 g and in head circumference by 1 cm when DNA adducts, a marker for environmental toxin exposure, were doubled in maternal blood. In Holland, a 48-g reduction in birthweight was reported. The World Trade Center disaster influenced pregnancy outcomes in New York, among ethnically Arab women living in California and among Dutch women. The adverse outcomes are likely due to environmental pollution and stress in New York, ethnic harassment in California and communal bereavement and stress in Holland.

To determine the detection rate of fetal structural abnormalities by a routine 11-14-week ultrasound scan for dating in an unselected pregnant population. A prospective observational cohort study of 2,708 unselected pregnant women attending an abdominal ultrasound examination at 11-14 weeks gestation. The number of major fetal structural abnormalities diagnosed after birth was obtained from a computerized database at the same unit. Out of 2,708 pregnant women, 89 (3.3%) were found to have a missed abortion at the time of the ultrasound scan and 33 (1.2%) were diagnosed as twins. Thirteen major structural abnormalities were detected, three cases of anencephaly (one case also had a spina bifida), one case with hydranencephaly, one fetus with Dandy-Walker syndrome, two cases with gastroschisis, one case with a bilateral hydronephrosis, one case with a generalized hydrops, one fetus with multiple malformations, and three cystic hygromas. An additional 19 major structural defects were detected at birth. Four cases of neural tube defects and nine fetuses with congenital heart defects were diagnosed. The antenatal ultrasound detection rate was 40.6% (13/32). Nine patients had a nuchal translucency greater than 3.0 mm (excluding cystic hygromas); two of them had chromosomal abnormalities (trisomy 21 and trisomy 18). Fetal structural abnormalities were detected in 41% (95%CI = 24-59) of the cases in an unselected pregnant population at a routine 11-14-week ultrasound scan for dating purpose. Two out of nine fetuses with a nuchal translucency greater than 3.0 mm had a chromosomal abnormality.

In 113 cases of fetal cardiac arrhythmia, i.e. 94 with supraventricular arrhythmia, 5 with atrioventricular block and 14 with ventricular arrhythmia, the clinical outcome was studied and compared with the general pregnant population. The arrhythmia group was afflicted with a significantly increased frequency of congenital malformations, 6.2% vs. 2.0%; fetal distress in labor, 20.4% vs. 13.5%; perinatal mortality, 3.5% vs. 0.7%; and neonatal mortality, 1.8% vs. 0.1%. In 4 cases, pharmacological cardiac treatment was needed in utero due to fetal heart failure. Fetuses with cardiac arrhythmia thus constitute an obstetric and pediatric high-risk group that should be subjected to an intensified supervision to detect fetal heart failure or fetal distress. When indicated, these complications can be treated in utero.

To identify prognostic factors influencing the outcome of infertility treatment using intrauterine insemination with donor semen (IUI-D). Retrospective study of all patients undergoing IUI-D between August 1st, 1990 and July 31st, 1998. University-affiliated infertility clinic. Three hundred and five couples undergoing 1131 IUI-D treatment cycles. Type of hormonal treatment, number of follicles, length of follicular phase, endometrial pattern, female age, infertility diagnosis and semen quality related to clinical pregnancy rate, cumulative birth rate and multiple gestations. Throughout the nine year period the overall clinical pregnancy rate per cycle was 22.3%, with an increase from 12.9% in 1990 to 34.6% in 1998. The multiple birth rate was 20.6%. The birth rate per couple was 61.1% after a mean of 3.2 treatment cycles. The pregnancy rate was highest in the first treatment cycle and the cumulative birth rate rose only slightly after the sixth treatment cycle. The following parameters were positively and significantly correlated to a successful outcome of IUI-D: i) the first treatment cycle - compared to the following up to six treatment cycles; ii) number of mature follicles - more than one - at the time of insemination, however, with an unacceptable high rate of multiple pregnancies when more than 3 mature follicles were present; iii) time of insemination after the 12th day in the cycle; iv) insemination after ovulation has occurred and; v) female age under 30 years. IUI-D is a simple and inexpensive treatment giving acceptable pregnancy rates for up to six treatment cycles if at least 2 mature follicles have developed at the time of insemination, which implies that hormonal ovarian stimulation and induction of ovulation is used, and ovulation has occurred at the time of insemination, which ought to take place after cycle day (cd) 12 with at least two million motile spermatozoa.

Sixty women in the third trimester of pregnancy were examined with 113mIn placental scintigraphy because of bleeding. In 24 of the cases, the scintigraphic procedure was initiated by application of a Meyers ring containing 113mIn round cervix. In the other cases, the fundus and the symphysis pubis were marked by means of a small radioactive source. Complete placenta praevia was correctly detected in 8 cases and marginal placenta in 4 cases. The scintigraphic localization of the placenta was correct in all the women where the ring was used, whereas when the external marked was used, seven errors occurred. The authors therefore recommend this new technique in order to facilitate the evaluation of the scintigrams.

The aim of this study was to identify the independent histopathologic prognostic factors for patients with cervical carcinoma treated with radical hysterectomy including paraaortic lymphadenectomy. A total of 187 patients with stage IB to IIB cervical carcinomas treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy were retrospectively analyzed. The median follow-up period was 83 months. Cox regression analysis was used to select independent prognostic factors. Using multivariate Cox regression analysis, lymph node (LN) status (negative vs. metastasis to pelvic nodes except for common iliac nodes vs. common iliac/paraaortic node metastasis), histopathologic parametrial invasion, lymph-vascular space invasion (LVSI), and histology of pure adenocarcinoma were found to be independently related to patients' poor survival. For patients who had a tumor histologically confined to the uterus and have neither parametrial invasion nor lymph node metastasis, LVSI was the most important prognostic factor, and histologic type, depth of cervical stromal invasion, and tumor size were not related to survival. The survival of patients with a tumor extending to parametrium or pelvic lymph node(s) was adversely affected by histology of pure adenocarcinoma. When the tumor extended to common iliac or paraaortic nodes, patients' survival became quite poor irrespective of LVSI or histologic type of pure adenocarcinoma. Patients' prognosis could be stratified into low risk (patients with a tumor confined to the uterus not associated with LVSI: n = 80), intermediate risk (patients with a tumor confined to the uterus associated with positive LVSI, and patients with squamous/adenosquamous carcinoma associated with pelvic lymph node metastasis or parametrial invasion: n = 86), and high risk (patients with pure adenocarcinoma associated with pelvic lymph node metastasis or parametrial invasion, and patients with common iliac/paraaortic node metastasis: n = 21) with an estimated 5-year survival rate of 100 +/- 0 (mean +/- SE)%, 85.5 +/- 3.9%, and 25.1 +/- 9.7%, respectively. LN status, parametrial invasion, LVSI, and histology of pure adenocarcinoma are important histopathologic prognostic factors of cervical carcinoma treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy. Prognosis for patients with cervical carcinoma may be stratified by combined analysis of these histopathologic prognostic factors. Postoperative therapy needs to be individualized according to these prognostic factors and validated for its efficacy using randomized clinical trials.