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Objective: The purpose of the study was to determine the angiogenic capacity of sera in early and late pregnancy and in umbilical blood serum after childbirth, and to define how angiogenic properties assessed in a functional in vitro test are related to individual angiogenic proteins in six women with pre-eclampsia and in six healthy pregnant controls., Methods: Maternal first and third trimester serum samples, and umbilical blood samples after childbirth, were tested in an in vitro human adipose stromal cell-human umbilical vein endothelial cell (hASC-HUVEC) vasculogenesis/angiogenesis assay. The angiogenic properties of the samples were measured by quantifying tubule formation. Concentrations of total placental growth factor (PlGF), total vascular endothelial growth factor (VEGF), soluble fms-like tyrosine kinase 1 (sFlt-1) and soluble endoglin (sEng) were determined by immunoassay., Results: First-trimester maternal sera of both groups had a stimulatory effect on angiogenesis in vitro and levels of angiogenic proteins did not differ between the groups. Third-trimester maternal sera in the pre-eclampsia group had an inhibitory effect on tubule formation, while those from normal pregnancies remained stimulatory. Compared with the first trimester there was a significant change in the concentrations of angiogenic proteins toward an anti-angiogenic state in pre-eclampsia. Umbilical blood serum exhibited strong anti-angiogenic effects without a significant difference between groups., Conclusions: Third-trimester serum of pre-eclamptic patients is anti-angiogenic. This phenomenon is not yet present in the first trimester. Umbilical blood serum shows inhibitory effects on angiogenesis after normal as well as pre-eclamptic pregnancy.

Background: Placental alpha microglobulin-1 and phosphorylated insulin-like growth factor-binding protein-1 have been studied in patients at risk for preterm birth with signs and symptoms of preterm labor. However, a direct comparison between these 2 biomarkers, alone or in combination with cervical length measurement with an adequate sample size, has been lacking to date., Objective: The purpose of this study was to compare the placental alpha microglobulin-1 test and the phosphorylated insulin-like growth factor-binding protein-1 test alone and in combination with cervical length measurement for the prediction of imminent spontaneous preterm birth of testing in pregnant women with symptoms of preterm labor in a tertiary care setting., Study Design: Four hundred three patients with intact amniotic membranes and cervical dilation ≤3 cm, without recent intercourse or cerclage, between gestational weeks of 20 +0 and 36 +6 were recruited prospectively from 3 international centers. Placental alpha microglobulin-1 and phosphorylated insulin-like growth factor-binding protein-1 tests were conducted before cervical length measurement via transvaginal ultrasound scanning. Caregivers were blinded to the biomarker test results. Medically indicated deliveries within 14 days of testing were excluded. Standard performance statistics with 95% confidence intervals were calculated and compared based on pairwise estimates from a generalized model., Results: Of 403 subjects who were enrolled in the study cohort, 94% (383/403 women) met the inclusion criteria. Median gestational age and cervical length at presentation were 30 +5 weeks and 27 mm, respectively; 6.8% women (26/383 women) had spontaneous birth ≤7 days from testing. The placental alpha microglobulin-1 test was positive in 7.8% of the women (30/383 women); the phosphorylated insulin-like growth factor-binding protein-1 test was positive in 29.5% women (113/383 women). Positive predictive value for placental alpha microglobulin-1, phosphorylated insulin-like growth factor-binding protein-1, and cervical length <25 mm for the prediction of spontaneous preterm birth in the overall cohort was 60.0% (18/30 women), 18.6% (21/113 women), 11.8% (18/152 women), respectively. The negative predictive value was 97.7% (345/353 women), 98.2% (265/270 women), 96.5% (223/231 women), respectively. The prevalence of spontaneous preterm birth in this group was 6.8% (26/383 women). The positive likelihood ratios were 20.6, 3.1, and 1.8, respectively. The negative likelihood ratio were 0.3, 0.3, and 0.5, respectively. Positive predictive values for placental alpha microglobulin-1 and phosphorylated insulin-like growth factor-binding protein-1 tests in patients with cervical length shortening of 15-30 mm for the prediction of spontaneous preterm birth were 60.9% (14/23 women) and 28.1% (16/57 women), respectively. The negative predictive values were 97.1% (168/173 women) and 97.8% (136/139 women), respectively. The prevalence of spontaneous preterm birth in the 15-30 mm cohort was 9.7% (19/196 women). The positive likelihood ratios were 14.5 and 3.6, respectively. The negative likelihood ratios were 0.3 and 0.2, respectively., Conclusion: Placental alpha microglobulin-1 is significantly more specific than phosphorylated insulin-like growth factor-binding protein-1 for the prediction of spontaneous preterm birth ≤7 days (P<.0001), whereas both tests have comparable sensitivity. In patients with cervical length 15-30 mm, although placental alpha microglobulin-1 has a significantly higher positive predictive value and specificity compared with phosphorylated insulin-like growth factor-binding protein-1 for the prediction of spontaneous preterm birth at ≤7 days (P<.01), both tests have a comparable sensitivity and negative predictive value. In conclusion, placental alpha microglobulin-1 is a better predictor of imminent spontaneous preterm birth when compared with phosphorylated insulin-like growth factor-binding protein-1 alone or in combination with cervical length measurement. In patients with shortening of cervical length of 15-30 mm, the placental alpha microglobulin-1 test is a significantly better predictor of imminent spontaneous preterm birth within 7 days of testing than is phosphorylated insulin-like growth factor-binding protein-1., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Purpose of this study was to investigate differences between primiparous term pregnancies, one leading to vaginal delivery (VD) and the other to acute cesarean section (CS) due to labor dystocia in the first stage of labor. We particularly wanted to assess the influence of body mass index (BMI) on CS risk., Methods: A retrospective case-control study in a tertiary delivery unit with 5200 deliveries annually. Cases were 296 term primiparous women whose intended vaginal labor ended in acute CS because of dystocia. Controls were primiparas with successful vaginal delivery VD (n = 302). The data were retrieved from medical records. Multiple logistic regression analyses were used to assess the associations between BMI and covariates on labor dystocia., Results: In the cases ending with acute CS, women were older (OR 1.06 [1.03-1.10]), shorter (OR 0.94 [0.91-0.96]) and more often had a chronic disease (OR 1.60 [1.1-2.29]). In this group fetal malposition (OR 42.0 [19.2-91.9]) and chorioamnionitis (OR 10.9 [5.01-23.6]) were more common, labor was less often in an active phase (OR 3.37 [2.38-4.76]) and the cervix was not as well ripened (1.5 vs. 2.5 cm, OR 0.57 [0.48-0.67] on arrival at the birth unit. BMI was higher in the dystocia group (24.1 vs. 22.6 kg/m 2 , p < 0.001), and rising maternal pre-pregnancy BMI had a strong association with dystocia risk. If BMI increased by 1 kg/m 2 , the risk of CS was 10% elevated. Among obese primiparas, premature rupture of membranes, chorioamnionitis and induction of labor were more common. Their labors were less often in an active phase at hospital admission. Severely obese primiparas (BMI ≥ 35 kg/m 2 ) had 4 hours longer labor than normal-weight parturients., Conclusions: Labor dystocia is a multifactorial phenomenon in which the possibility to ameliorate the condition via medical treatment is limited. Hospital admission at an advanced stage of labor is recommended. Pre-pregnancy weight control in the population at reproductive age is essential, as a high BMI is strongly associated with labor dystocia.

Objectives: Little is known about the significance of Streptococcus G or C colonization in pregnant women. The objective of this study was to assess whether vaginal Streptococcus group G or C colonization detected in late pregnancy increases the infectious morbidity of the mother or newborn., Methods: A total of 15,114 rectovaginal cultures taken at 35-37 weeks of pregnancy were analyzed at Tampere University Hospital, Finland, between 2012 and 2014. From this laboratory data, all Streptococcus G or C-positive cultures were included to study maternal and neonatal infectious morbidity after delivery. This study population was compared to women with a positive Streptococcus B culture and to women with a negative culture., Results: The prevalence of Streptococcus G or C colonization was 2.9%. Significantly more postpartum endometritis was found in this study group. No association was found between colonization and neonatal bacteremia., Conclusions: Streptococcus G or C colonization is associated with postpartum endometritis. More research is needed to clarify if antibiotic prophylaxis is reasonable for this group during delivery.

Objective: To compare neonatal and maternal outcomes in spontaneously onset preterm breech deliveries after trial of labor (BTOL) and intended cesarean section (BCS), and between BTOL and vertex control deliveries, in singleton fetuses at 32 +0 -36 +6  weeks of gestation., Study Design: Retrospective single center cohort study in a Finnish University Hospital including all spontaneous-onset preterm breech deliveries with 32 completed gestational weeks in 2003-2015. The study population comprised a total of 176 preterm breech and 103 vertex control deliveries, matched by gestational age and whether the mother had given birth vaginally before or not. Infants with severe malformations and antepartum fetal distress were excluded. Subgroup analyses were made in two cohorts according to gestational age. Main outcome measures were maternal and neonatal mortality and morbidity, low cord pH and Apgar score., Results: No mortality was observed, and severe morbidity was rare. No difference in incidence of low cord pH or five-minute Apgar score was observed between the groups. Apgar scores at the age of one minute were comparable in the breech groups but more often low in the BTOL group compared to the vertex control group. 16.5% of neonates in the BTOL group, 23.3% in the BCS group and 7.8% in the vertex group needed intensive care. In logistic regression analysis, lower gestational age and being small for gestational age were associated with the need for neonatal intensive care. Being allowed a trial of labor was not associated with the need for neonatal intensive care. Maternal morbidity was similar across the groups, but median blood loss was more pronounced in the BCS group compared to the BTOL group., Conclusion: In breech deliveries at 32 +0 -36 +6 gestational weeks, trial of labor did not increase neonatal morbidity compared to intended cesarean delivery. Infants born after a trial of labor in breech presentation display low one-minute Apgar score and need intensive care more often compared to vertex controls., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To assess the incidence and risk factors of asthma and atopic dermatitis by seven years of age after early-term (ET) (37 +0 -38 +6 weeks), full-term (FT) (39 +0 -40 +6 weeks), late-term (LT) (41 +0 -41 +6 weeks), and especially post-term (PT) (≥42 weeks) birth., Methods: Altogether, 965 203 infants born between 1991 and 2008 in Finland were investigated in ET, FT, LT, and PT groups. Data on asthma medication reimbursement and hospital visits for atopic dermatitis were retrieved from national health databases., Results: The frequencies of asthma medication reimbursement in the ET, FT, LT, and PT groups were 4.5%, 3.7%, 3.3%, and 3.2%, respectively. Hospital visits due to atopic dermatitis were most common after PT birth. Compared with FT births, ET births were associated with an increased risk of asthma (adjusted odds ratio (aOR), 95% confidence interval (CI) 1.20, 1.17-1.23), while LT (aOR, 95%CI 0.91, 0.89-0.93) births and PT (aOR, 95%CI 0.87, 0.83-0.92) births decreased this risk. PT birth (aOR, 95%CI 1.06, 1.01-1.10) predicted atopic dermatitis. From a population point of view, the most relevant risk factors for asthma were male sex, ET birth, smoking during pregnancy and birth by elective cesarean section, and for atopic dermatitis male sex, first delivery, birth in a level II hospital and birth by cesarean section., Conclusions: Early-term birth was a predictor of asthma, and PT birth was associated with atopic dermatitis. Counseling against smoking and following strict indications for planned ET deliveries and cesarean sections may be means to reduce the risk of later asthma., (© 2018 Wiley Periodicals, Inc.)

Background: The aim of the present study was to evaluate the subjective outcome of primary repair of obstetric anal sphincter injury (OASIS) at 6 months, the factors associated with the symptoms of anal incontinence (AI), and the role of a simple survey consisting in one question with three answer choices, combined with the Wexner incontinence score for the assessment of this patient population., Methods: A retrospective cohort study was conducted on patients with third- or fourth-degree OASIS operated on between January 2007 and December 2013 inclusive at Tampere University Hospital, Finland. At 6 months, the patients were asked to report their Wexner's score as well as the three-choice assessment regarding AI symptoms. Based on this assessment, the patients were divided into three groups: those, asymptomatic, those with mild symptoms who did not want further treatment and those with severe symptoms who were willing to undergo further evaluation and treatment., Results: There were 325 patients (median age 30 years). A total of 310 patients answered the questionnaire. Of which, one hundred and ninety-eight (63.9%) patients were asymptomatic, 85 (27.4%) had mild AI, and 27 (8.7%) experienced severe symptoms. There was no statistical difference in the results between the two techniques used (overlapping vs. end-to-end), or the stage of specialization of the operating physician. Persistent symptoms were associated with instrumental vaginal delivery (OR 2.12, 95% CI 1.32-3.41), severity of the injury (OR 1.64, 95% CI 1.20-2.25), and increased maternal age (OR 1.07, 95% CI 1.02-1.13). The correlation between the three-choice symptom evaluation and the Wexner score was good (Spearman's rho 0.82)., Conclusions: After 6 months, severe symptoms after OASIS repair were present in 9% of women and were more frequent in older women, women with high-degree tears and after instrumental vaginal delivery. A three-choice assessment of AI symptoms correlated well with the Wexner score and might be useful to triage patients who need further evaluation.

Introduction: Although metabolic syndrome (MetS) is evidently associated with the risk of cardiovascular disease (CVD), recently its use has been questioned. We studied the utility of MetS diagnosis when estimating individual CVD risk., Methods: We compared 27 fertile women with MetS and 27 counterparts without the syndrome, matched pairwise according to well-known risk factors of CVD. Pulse wave velocity (PWV) and central blood pressure (cBP) were determined noninvasively via a SphygmoCor device. Arterial compliance was measured noninvasively with an HDI/PulseWave TM CR-2000 arterial tonometer., Results: PWV (7.1 ± 2.5 versus 6.5 ± 1.1 m/s, p = .037), and both systolic (120.9 ± 12.2 versus 111.5 ± 16.0 mmHg, p = .031) and diastolic cBP (81.3 ± 8.5 versus 74.1 ± 11.2 mmHg, p = .035) were higher in the MetS group. Systemic arterial compliance values were lower in both large (15.1 ± 8.0 versus 16.1 ± 4.4 mL/mmHg × 10, p = .034) and small arteries (7.1 ± 2.5 versus 9.3 ± 3.2 mL/mmHg ×100, p = .010) in women with MetS., Conclusions: Fertile women with MetS had increased arterial stiffness, as measured by three different methods. Our results highlight the utility of MetS when revealing increased individual CVD risks in fertile-aged women. Key messages Women with MetS have increased arterial stiffness when measured by different methods. MetS is a useful clinical tool to assess increased cardiovascular risk, particularly among fertile-aged women.

Objective: To study the associations between a wide range of parental psychiatric disorders and offspring attention-deficit/hyperactivity disorder (ADHD)., Method: This study is based on a nested case-control design. The association between parental registered psychiatric diagnoses and offspring ADHD was examined adjusting for socioeconomic and prenatal factors. Data was linked from Finnish nationwide registers. The cases (n = 10,409) were all the children born between years 1991 and 2005 in Finland and diagnosed with ADHD by the end of 2011. Four controls without ADHD (n = 39,124) were matched for every case by sex, age and place of birth. Main outcomes were adjusted odds ratio (aOR) for parental diagnosis of cases vs controls. Analyses were further stratified by sex. Disorders diagnosed before and after birth were analyzed separately., Results: The odds ratio for ADHD increased when only mother (aOR 2.2, 95% CI 2.0-2.3), only father (aOR 1.7, 95% CI 1.6-1.8) and both parents (aOR 3.6, 95% CI 3.3-4.0) were diagnosed. Maternal diagnosis showed stronger association than paternal. The weight of association between several parental disorders and offspring ADHD were similar. Maternal psychopathology overall showed stronger associations with girls than boys with ADHD. The diagnoses registered after birth did not show stronger association than the diagnoses registered before., Conclusions: Maternal psychopathology showing stronger association than paternal implies that environmental factors or their interaction with genetic factors partly mediates the risk of parental psychopathology. Similar associations between several maternal psychiatric disorders and offspring ADHD points towards the need for investigating some common mother-related risk factors., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: Sleep during pregnancy involves a physiological challenge to provide sufficient gas exchange to the fetus. Enhanced ventilatory responses to hypercapnia and hypoxia may protect from deficient gas exchange, but sleep-disordered breathing (SDB) may predispose to adverse events. The aim of this study was to analyze sleep and breathing in healthy pregnant women compared to non-pregnant controls, with a focus on CO 2 changes and upper-airway flow limitation., Methods: Healthy women in the third trimester and healthy non-pregnant women with normal body mass index (BMI) were recruited for polysomnography. Conventional analysis of sleep and breathing was performed. Transcutaneous carbon dioxide (TcCO 2 ) was determined for each sleep stage. Flow-limitation was analyzed using the flattening index and TcCO 2 values were recorded for every inspiration., Results: Eighteen pregnant women and 12 controls were studied. Pregnancy was associated with shorter sleep duration and more superficial sleep. Apnea-hypopnea index, arterial oxyhemoglobin desaturation, flow-limitation, snoring or periodic leg movements were similar in the two groups. Mean SaO 2 and minimum SaO 2 were lower and average heart rate was higher in the pregnant group. TcCO 2 levels did not differ between groups but variance of TcCO 2 was smaller in pregnant women during non-rapid eye movement (NREM). TcCO 2 profiles showed transient TcCO 2 peaks, which seem specific to pregnancy., Conclusions: Healthy pregnancy does not predispose to SDB. Enhanced ventilatory control manifests as narrowing threshold of TcCO 2 between wakefulness and sleep. Pregnant women have a tendency for rapid CO 2 increases during sleep which might have harmful consequences if not properly compensated., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Introduction: Women with epilepsy (WWE) are generally treated as a risk group during pregnancy, but over 90% of pregnant WWE have favorable pregnancies. However, the risk of some pregnancy and delivery complications may be increased among WWE, especially those on antiepileptic drugs., Material and Methods: This nationwide, retrospective population-based cohort study includes WWE who gave birth in Finland during 1987-2008 (n = 1737) and the reference cohort of a random sample of women without epilepsy (n = 4357). Identification of the cohorts, and information on hospitalizations and deliveries were obtained from the Finnish Health Registers and population statistics. Multivariate analyses were conducted by binomial regression., Results: WWE were more often hospitalized during pregnancy for accidents or other external causes [adjusted risk ratio (aRR) 1.74, 95% confidence interval (CI) 0.98-3.09], premature rupture of membranes (aRR 1.75, 95% CI 1.14-2.69) and premature contractions (aRR 1.75, 95% CI 1.36-2.23). Hospitalizations for infections were more frequent in WWE (1.4% vs. 0.4%, aRR 3.15, 95% CI 1.72-5.76). The risk for induction of delivery or a cesarean section was increased in WWE. There was no difference in premature deliveries between the groups, but the risk of being small for gestational age (aRR 1.57, 95% CI 1.23-2.01), admission to neonatal intensive care unit (aRR 1.66, 95% CI 1.39-1.97), and need for respiratory care (aRR 2.37, 95% CI 1.57-3.60) was clearly increased in the offspring of WWE., Conclusions: WWE are at an increased risk of complications and hospitalizations during pregnancy and delivery. However, the majority of WWE have a normal pregnancy and delivery., (© 2017 Nordic Federation of Societies of Obstetrics and Gynecology.)

Introduction: The main aims of this study were to compare maternal and neonatal outcomes in term twin birth according to the planned mode of delivery and to study the effects of chorionicity and inter-twin delivery time on neonatal outcome., Material and Methods: A single-center cohort study of 495 women with twin deliveries at ≥37 +0 weeks of gestation. Term twin deliveries were divided into a trial of labor group (TOL, 69.3%) and a planned cesarean section (CS) group (30.7%). The primary outcomes were maternal and neonatal morbidity., Results: 80.8% of women attempting TOL achieved vaginal birth. In the TOL group, mothers had less bleeding [median 500 mL (range 150-2700 mL) vs. 950 mL (range 150-3500 mL), p < 0.001) and fewer surgical complications (3.2% vs. 8.6%, p = 0.011), whereas second twins more often had five-minute Apgar scores of <7 (5.0% vs. 0%, p = 0.002) or umbilical artery pH < 7.05 (5.7% vs. 0%, p = 0.003), compared with the planned CS group. There was a slight, non-significant tendency for more NICU admissions in the TOL group, yet the need for NICU treatment was infrequent in the whole study material. Outcomes among dichorionic (DC) second twins were similar to those in the whole material, but among monochorionic (MC) second twins there were no differences between the TOL and planned CS groups. In secondary analysis, a five-minute Apgar score <7 occurred significantly more often in the DC group among second twins if the inter-twin delivery time exceeded 30 min., Conclusions: TOL is a good option for women with twin pregnancy at term, regardless of chorionicity. Active management of labor for the second twin is important, also in DC births. Maternal outcomes were more favorable with TOL and although low Apgar scores and low umbilical blood pH may be more frequent after TOL - especially with the second twin - serious neonatal morbidity is rare and does not differ from that after planned CS., (© 2017 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: Gestational diabetes mellitus (GDM) has significant implications for the future health of the mother. Some clinical studies have suggested subclinical inflammation and vascular dysfunction after GDM. We aimed to study whether concentrations of high-sensitivity C-reactive protein (hsCRP), tissue inhibitor of metalloproteinase-1 (TIMP-1), matrix metalloproteinase-8 (MMP-8) and -9, as well as values of arterial stiffness differ between women with and without a history of GDM a few years after delivery. We also investigated possible effects of obesity on the results., Methods: We studied two cohorts-120 women with a history of GDM and 120 controls-on average 3.7 years after delivery. Serum concentrations of hsCRP were determined by immunonephelometric and immunoturbidimetric methods, MMP-8 by immunofluorometric assay, and MMP-9 and TIMP-1 by enzyme-linked immunosorbent assays. Pulse wave velocity (PWV) was determined using the foot-to-foot velocity method from carotid and femoral waveforms by using a SphygmoCor device. Arterial compliance was measured non-invasively by an HDI/PulseWave™CR-2000 arterial tonometer. All 240 women were also included in subgroup analyses to study the effect of obesity on the results. Multiple linear regression analyses were performed with adjustment for confounding factors., Results: PWV after pregnancy complicated by GDM was significantly higher than after normal pregnancy, 6.44 ± 0.83 (SD) vs. 6.17 ± 0.74 m/s (p = 0.009). Previous GDM was also one of the significant determinants of PWV in multiple linear regression analyses. On the other hand, compliance indices of both large (p = 0.092) and small (p = 0.681) arteries did not differ between the study cohorts. Serum TIMP-1 levels were significantly increased after previous GDM (p = 0.020). However, no differences were found in the serum levels of MMP-8, MMP-9 or hsCRP. In subgroup analyses, there were significantly higher concentrations of hsCRP (p = 0.015) and higher PWV (p < 0.001) among obese women compared with non-obese ones., Conclusions: PWV values were significantly higher after GDM compared with normoglycemic pregnancies and were associated with prolonged TIMP-1 upregulation. Cardiovascular risk factors were more common in participants with high BMI than in those with previous GDM.

Introduction: Gestational diabetes mellitus (GDM) is an indicator of future cardiovascular disease. We investigated whether sensitive biomarkers of increased cardiovascular risk differ between women with and without a history of GDM few years after pregnancy, and whether obesity affects the results., Material and Methods: We studied two cohorts - 120 women with a history of GDM and 120 controls, on average 3.7 years after delivery. Circulating concentrations of oxidized low-density lipoprotein (oxLDL) were determined by ELISA. The homeostasis model assessment of insulin resistance (HOMA-IR) index was used to estimate insulin resistance. Central blood pressure (cBP) was measured noninvasively from a radial artery pulse wave. The primary outcomes were possible differences in oxLDL, HOMA-IR or cBP between the groups. Secondly, we investigated the influence of obesity on the results, also using adjusted multiple linear regression analyses., Results: OxLDL concentrations or cBP did not differ between the two cohorts, but HOMA-IR was significantly higher in women with previous GDM than in controls, 1.3 ± 0.9 (SD) and 1.1 ± 0.9, respectively (p = 0.022). In subgroup analyses, HOMA-IR (p < 0.001), systolic (p < 0.001) and diastolic (p < 0.001) cBP were significantly higher in obese subgroups compared with non-obese ones. Body mass index was an important determinant of HOMA-IR and cBP in multiple linear regression analyses., Conclusions: Over 3 years after delivery, women with GDM were still more insulin-resistant than controls. Obesity turned out to be a more important determinant of insulin resistance and cBP compared with GDM., (© 2016 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: The safety of vaginal breech delivery has been debated for decades. Although it has been shown to predispose infants to immediate depression, several observational studies have also shown that attempting vaginal breech delivery does not increase perinatal morbidity or low Apgar score at the age of five minutes. Cardiotocography monitoring is recommended during vaginal breech delivery, but comparative data describing differences between cardiotocography tracings in breech and vertex deliveries is scarce. This study aims to evaluate differences in intrapartum cardiotocography tracings between breech and vertex deliveries in the final 60 min of delivery. A secondary goal is to identify risk factors for suboptimal neonatal outcome in the study population., Methods: One hundred eight breech and 108 vertex singleton, intended vaginal deliveries at term from a tertiary hospital with 5000 annual deliveries were included. Two experienced obstetricians, blinded to fetal presentation, neonatal outcome and actual mode of delivery, evaluated traces recorded 60 min before delivery. They provided a three-tier classification and evaluated different trace features according to FIGO (1987) guidelines. Factors associated with acidemia and low Apgar scores were identified by univariate and multivariable analyses performed with binary logistic regression. Student's T-test and chi-square test were used, as appropriate., Results: Late decelerations were seen in 13.9 % of breech and 2.8 % of vertex deliveries (p = 0.003) and decreased variability in 26.9 % of breech and 8.3 % of vertex deliveries (p < 0.001). In multivariable analysis complicated variable decelerations and breech presentation were identified as risk factors for neonatal acidemia and low Apgar score at the age of five minutes. Pathological trace and breech presentation were independent risk factors for low Apgar score at the age of one minute., Conclusions: Decreased variability and late decelerations were more prevalent in breech compared to vertex deliveries. Pathological trace predicts immediate neonatal depression and especially complicated variable decelerations may signal more severe distress. Further research is needed to create guidelines for safe management of vaginal breech delivery.

Objective: To explore in vitro angiogenic properties of maternal and umbilical cord blood sera from women with symptomatic pre-eclampsia in comparison with sera from women with normotensive pregnancies., Study Design: Maternal and umbilical blood serum samples were collected from eleven primiparous women with pre-eclampsia and ten healthy gestational-age-matched primiparous controls. The samples were tested for tubule formation in two different types of in vitro angiogenesis tests. The first test (fibroblast-HUVEC) showed effects on angiogenesis and the second test (hASC-HUVEC), in addition to angiogenesis, also showed effects on vasculogenesis. The pro-angiogenic and inhibitory properties of the samples were microscopically quantified after immunostaining tubular structures, using markers for von Willebrand factor (vWf) and collagen IV., Results: Serum samples from pre-eclamptic women inhibited tubule formation in both models, while those from normal pregnancy didn't. Umbilical blood samples were inhibitory both after pre-eclampsia and normal pregnancy. In the fibroblast-HUVEC model the inhibition was stronger after preeclampsia pregnancy, and the difference between groups was statistically significant. In the pre-eclampsia group a correlation between the inhibitory effect of umbilical blood and birth weight adjusted to gestational age was found. No clear correlation between sera from pregnant women and corresponding umbilical sera was found., Conclusion: The strong inhibitory effect of maternal serum samples on tubule formation reflects the anti-angiogenic state that is present in pre-eclampsia., (Copyright © 2016 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Background: Women with gestational diabetes mellitus (GDM) are at an increased risk of developing metabolic syndrome (MetS) after delivery. Recently, the prevalence of both GDM and MetS has increased worldwide, in parallel with obesity. We investigated whether the presentation of MetS and its clinical features among women with previous GDM differs from that among those with normal glucose tolerance during pregnancy, and whether excess body weight affects the results., Methods: This hospital-based study of two cohorts was performed in Kanta-Häme Central Hospital, Finland. 120 women with a history of GDM and 120 women with a history of normal glucose metabolism during pregnancy, all aged between 25 and 46 were enrolled. They all underwent physical examination and had baseline blood samples taken. All 240 women were also included in subgroup analyses to study the effect of excess body weight on the results., Results: Although the groups did not differ in body mass index (BMI; p = 0.069), the risk of developing MetS after pregnancy complicated by GDM was significantly higher than after normal pregnancy, 19 vs. 8 cases (p  =  0.039). Fasting glucose (p < 0.001) and triglyceride levels (p < 0.001) were significantly higher in women affected. In subgroup analysis, cardiovascular risk factors were more common in participants with high BMI than in those with previous gestational diabetes., Conclusions: The risk of MetS was 2.4-fold higher after GDM than after normal pregnancy. Cardiovascular risk factors were more common in participants with high BMI than in those with previous GDM. Multivariate analysis supported the main findings. Weight control is important in preventing MetS after delivery.

Objective: Outcome after intrauterine transfusions due to severe hemolytic disease of the fetus and newborn., Design: Nationwide population-based retrospective cohort study., Setting: All women treated with intrauterine transfusions for hemolytic disease of the fetus and newborn in Finland in 2003-2012., Population: 339 intrauterine transfusions, performed in 104 pregnancies of 84 women., Methods: Information on antenatal screening of red cell antibodies and red cell units issued for intrauterine transfusion was obtained from the Finnish Red Cross Blood Service database, and obstetric and neonatal data from hospital records., Main Outcome Measures: Procedure-related complications, perinatal mortality, neonatal morbidity., Results: Overall survival was 94.2% (95% confidence interval 89.7-98.7). There were four fetal and two neonatal deaths. Procedure-related fetal loss rate was 1.2% (95% confidence interval 0.04-2.4) per procedure and 3.8% (95% confidence interval 0.1-7.5) per pregnancy. Of the four procedure-related losses, three were due to technically difficult intrauterine transfusions causing infection and preterm birth. Of the live born infants, 19% (95% confidence interval 11.3-26.7) were born before 32 weeks' gestation. The incidence of severe neonatal morbidity (respiratory distress syndrome, severe cerebral injury, sepsis) was 22.2% (95% confidence interval 13.4-30.2). Poor outcome (death, severe neonatal morbidity) was negatively associated with gestational age at first transfusion (p = 0.001) and at birth (p = 0.00006). Follow-up of the infants was too incomplete to assess the neurodevelopmental outcome., Conclusions: Although overall survival is comparable with previous studies, our concern is procedure-related infections and preterm births. Close collaboration between the university hospitals is needed to ensure timely treatment, operator skills and systematic follow-up of the children., (© 2015 Nordic Federation of Societies of Obstetrics and Gynecology.)

The formation of blood vessels is a vital process in embryonic development and in normal physiology. Current vascular modelling is mainly based on animal biology leading to species-to-species variation when extrapolating the results to humans. Although there are a few human cell based vascular models available these assays are insufficiently characterized in terms of culture conditions and developmental stage of vascular structures. Therefore, well characterized vascular models with human relevance are needed for basic research, embryotoxicity testing, development of therapeutic strategies and for tissue engineering. We have previously shown that the in vitro vascular model based on co-culture of human adipose stromal cells (hASC) and human umbilical vein endothelial cells (HUVEC) is able to induce an extensive vascular-like network with high reproducibility. In this work we developed a defined serum-free vascular stimulation medium (VSM) and performed further characterization in terms of cell identity, maturation and structure to obtain a thoroughly characterized in vitro vascular model to replace or reduce corresponding animal experiments. The results showed that the novel vascular stimulation medium induced intact and evenly distributed vascular-like network with morphology of mature vessels. Electron microscopic analysis assured the three-dimensional microstructure of the network containing lumen. Additionally, elevated expressions of the main human angiogenesis-related genes were detected. In conclusion, with the new defined medium the vascular model can be utilized as a characterized test system for chemical testing as well as in creating vascularized tissue models.

Background: The optimal mode of breech birth remains controversial. In Finland, a trial of vaginal delivery is possible if strict selection criteria are met. As clinical practice in managing vaginal breech birth differs from that in normal delivery, the birth experience may also be different. This cohort study compares the childbirth experience between term breech and vertex deliveries., Methods: Intended vaginal term breech births from 2008 to October 2012 were included, and for every breech delivery, a vertex control was selected. The proportions of deliveries ending in a cesarean section and of mothers who had given birth vaginally before were equal in both groups. Three hundred eight mothers were sent the childbirth experience questionnaire and 170 returned it., Results: The birth experience does not differ between breech and vertex births, except for aspects with respect to the choice of birthing position. Indications of an even more positive experience were observed in the breech group, with the exception of the choice of analgesia, but these were not statistically significant. Primiparity, emergency cesarean section, infant birth trauma and prolonged hospital stay were identified as risk factors for a negative birth experience., Conclusion: The birth experience of vaginal breech birth seems to be at least as positive as the vaginal vertex birth experience., (© 2014 Wiley Periodicals, Inc.)

Preeclampsia is a serious and phenotypically heterogeneous vascular pregnancy disorder. Heme oxygenase-1 (HO-1) is a stress response enzyme that may protect the maternal endothelium and facilitate adequate metabolic adaptation to pregnancy by its antioxidant and anti-inflammatory functions. HO-1 stress response is modulated by HO-1 gene (HMOX1) polymorphisms. Individuals with the long allele of a guanine-thymine (GTn) microsatellite repeat located in the promoter region of HMOX1 have a higher risk of cardiometabolic diseases compared with those with the short allele. We investigated whether the long GTn allele of HMOX1 is associated with subtypes of preeclampsia. The GTn repeat was genotyped in 759 patients and in 779 controls from the Finnish Genetics of Preeclampsia Consortium (FINNPEC) cohort using DNA fragment analysis. In subtype analyses, the long-long (LL) genotype was associated with nonsevere (additive model: odds ratio [OR], 1.94; 95% confidence interval [CI], 1.13-3.31; recessive model: OR, 1.39; 95% CI, 1.02-1.89) and late-onset (additive model: OR, 1.44; 95% CI, 1.02-2.05; recessive model: OR, 1.28; 95% CI, 1.02-1.59) preeclampsia and with preeclampsia without a small-for-gestational-age infant (recessive model: OR, 1.27; 95% CI, 1.02-1.58). The long allele was associated with nonsevere (OR, 1.35; 95% CI, 1.07-1.70) and late-onset (OR, 1.21; 95% CI, 1.03-1.42) preeclampsia and with preeclampsia without a small-for-gestational-age infant (OR, 1.19; 95% CI, 1.02-1.40). Moreover, both the LL genotype and the long allele were associated with preeclampsia in women who had smoked during pregnancy. In conclusion, the GTn long allele seems to predispose to late-onset, less severe form of preeclampsia. This finding supports the role of HO-1 in the pathogenesis of preeclampsia and suggests that the HO-1 pathway may provide a potential target for the treatment of preeclampsia., (© 2014 American Heart Association, Inc.)

Objectives: To examine the clinical risk factors and complications of shoulder dystocia today and to evaluate ultrasound methods predicting it., Study Design: Retrospective, matched case-control study at a University Hospital with 5000 annual deliveries. The study population consisted of 152 deliveries complicated by shoulder dystocia over a period of 8.5 years (January 2004-June 2012) and 152 controls matched for gestational age and parity. The data was collected from the medical records of mothers and children and analyzed by conditional logistic regression. Incidences and odds ratios were calculated for risk factors and complications. Antenatal ultrasound data was analyzed when available by conditional logistic regression to test for significant differences between study groups., Results: Birthweight (OR 12.1 for ≥4000 g; 95% CI 4.18-35.0) and vacuum extraction (OR 3.98; 95% CI 1.25-12.7) remained the most significant clinical risk factors. Only a trend of an association of pregestational or gestational diabetes was noticed (OR 1.87; 95% CI 0.997-3.495, probability of type II error 51%). Of the complications of shoulder dystocia the incidence of brachial plexus palsies was high (40%). Antenatal ultrasound method based on the difference between abdominal and biparietal diameters had a significant difference between cases and controls., Conclusions: The impact of diabetes as a risk factor has diminished, which may reflect improved screening and treatment. Antenatal ultrasound methods are showing some promise, but the predictive value of ultrasound alone is probably low., (Copyright © 2014. Published by Elsevier Ireland Ltd.)

Sleep disorders are common in pregnancy. Several hormonal and physiological changes have been shown to affect the quality of sleep. Sleep disorders have been related to various pregnancy complications, e.g. pre-eclampsia. In particular, sleep apnea is more common among women who develop hypertension in pregnancy or pre-eclampsia. Compared with control patients, snoring is similarly more often apparent in women who will have pre-eclampsia manifested. Hence, the relationship between sleep disorders and pre-eclampsia warrants investigation. CPAP treatment has been proven to be effective in sleep apnea, but also in lowering blood pressure. CPAP may be useful also in the prevention and treatment of pre-eclampsia.

Owing to the physiologic changes associated with pregnancy there is a considerably elevated risk of thrombosis during pregnancy and immediately after childbirth. Familial or acquired thrombophilia, i.e. tendency for thrombosis, increases the risk of pregnancy-related thrombosis. Recommendations for the prevention of pregnancy-related venous thromboses are not uniform - the risk of thrombosis must thus be evaluated on an individual basis. Critical clinical consideration should be undertaken when exploring familial thrombophilia in connection with pregnancy complications. Investigation of antiphospholipid antibodies is recommended in connection with certain pregnancy complications.

Objective: The aim of this study was to compare the rate of cesarean sections in 12 delivery units in Finland, and to assess possible associations between cesarean section rates and maternal and neonatal complications., Design: Prospective multicenter cohort study., Setting: The 12 largest delivery units in Finland., Population: Total obstetric population between 1 January 2005 and 30 June 2005 (n = 19 764)., Methods: Prospectively collected data on 2496 cesarean sections and data derived from the Finnish Birth Register on all deliveries in these units were compared. Cesarean section rates and maternal complication rates were adjusted for known risk factors., Main Outcome Measures: Cesarean section rate, maternal complications related to cesarean section, and neonatal asphyxia., Results: The cesarean section rates varied significantly between the hospitals (12.9-25.1%, p < 0.0001), as did the maternal complication rates related to cesarean section (13.0-36.5%, p < 0.0001). There was no relation between maternal complications and the cesarean section rate. The differences remained after adjusting for risk factors. Neonatal asphyxia rates varied between 0.14 and 2.8% (p < 0.0001) and were not related to the cesarean section rates., Conclusions: The rates of cesarean section, maternal complications and neonatal asphyxia vary markedly between different delivery units. Good maternal and neonatal outcomes can be achieved with cesarean section rates <15%., (© 2013 Nordic Federation of Societies of Obstetrics and Gynecology.)

Highly sensitive cantilever-enhanced photoacoustic detection of hydrogen cyanide and methane in the mid-infrared region is demonstrated. A mid-infrared continuous-wave frequency tunable optical parametric oscillator was used as a light source in the experimental setup. Noise equivalent detection limits of 190 ppt (1 s) and 65 ppt (30 s) were achieved for HCN and CH(4), respectively. The normalized noise equivalent absorption coefficient is 1.8 × 10(-9) W cm(-1) Hz(-1/2).

Objective: To compare the neonatal outcome between planned vaginal or planned cesarean section (CS) breech delivery and planned vaginal vertex delivery at term with singleton fetuses., Design: A cohort study., Setting: Delivery Unit, Tampere University Hospital, Finland, with 5200 annual deliveries., Population: The term breech deliveries over a period of five years (January 2004 to January 2009), a total of 751 breech deliveries, and 257 vertex controls., Methods: The data were collected from the mother's medical records, including a summary of the newborn. In the case of neonatal health problems, the pediatric records were also examined., Main Outcome Measures: Maternal and neonatal mortality and morbidity as defined in the Term Breech Trial. Low Apgar scores or umbilical cord pH as secondary end-points., Results: There was no neonatal mortality. Severe morbidity was rare in all groups, with no differences between groups. The Apgar scores at one minute were lower in the planned vaginal delivery group compared with the other groups, but there was no difference at the age of five minutes. Significantly more infants in the vaginal delivery group had a cord pH < 7.05. There was one maternal death due to a complicated CS in the planned CS group and none in the other groups. Mothers in the planned CS group suffered significantly more often from massive bleeding and needed transfusions., Conclusions: Vaginal delivery remains an acceptable option for breech delivery in selected cases., (© 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: To establish the association of cardiotocography (CTG) and other obstetric parameters with pulsed Doppler findings in cerebral arteries during the first day of life, and to compare the cerebral artery Doppler with other determinants of asphyxia in predicting 1-year neurological outcome in asphyxiated full-term infants., Study Design: Cerebral blood flow velocity (CBFV) were measured from the anterior cerebral (ACA) and basilar (BA) arteries in 30 asphyxiated and 30 healthy-term infants using pulsed Doppler ultrasonography at approximately 24 h of age. CTG, cord artery pH, Apgar scores, biochemical asphyxia markers and symptoms of hypoxic-ischemic encephalopathy (HIE) were compared with the Doppler findings in respect of the ability to predict the outcome, defined by death or impaired neurological performance at 1 year of age., Result: In all, 20% of the asphyxiated infants but none in the control group had increased peak systolic CBFVs (mean+3 s.d.) in the ACA or BA. The sensitivity of increased systolic CBFV to predict abnormal outcome in the asphyxia group was 83%, specificity 95% and the sensitivity of the combination of HIE grade from 2 to 3 and increased systolic CBFV in the ACA or BA was 100% and specificity was 95%, respectively. Pathological CTG and low cord artery pH or low Apgar scores showed low predictive power., Conclusion: Grade from 2 to 3 HIE and the systolic CBFV (mean+3 s.d.) in the ACA or BA by Doppler ultrasound seemed to predict the outcome in asphyxiated infants at 1 year of age better than CTG, acid basement status, Apgar scores or asphyxia markers. If an increase of more than +3 s.d. in the systolic CBFV does not occur within the first 24 h of life, a good 1-year neurological outcome may be anticipated.

Bilateral absence of the superior vena cava (SVC) is a very rarely detected, mainly asymptomatic congenital vascular anomaly. Though usually innocent, this anomaly may complicate cardiothoracic surgery and certain procedures like central venous catheter insertion. This SVC anomaly is poorly known, and we assume that its incidence in the general population may be higher than detected. In this paper, we summarize current knowledge on this anomaly and its clinical implications. In addition, we present a neonatal case with bilateral absence of the SVC associated with a fetal cystic hygroma. Conclusion. Totally absent SVC can cause unexpected problems during cardiothoracic surgery. Suspicion of SVC absence should arise in basic echocardiography. Our paper suggests that, like other congenital anomalies, bilateral absent SVC may be associated with a fetal cyctic hygroma.

The developed standardized human cell based in vitro angiogenesis assay was intra-laboratory pre-validated to verify that the method is reliable and relevant for routine testing of modulators of angiogenesis, e.g., pharmaceuticals and industrial chemicals. This assay is based on the earlier published method but it was improved and shown to be more sensitive and rapid than the previous assay. The performance of the assay was assessed by using six reference chemicals, which are widely used pharmaceuticals that inhibit angiogenesis: acetyl salicylic acid, erlotinib, 2-methoxyestradiol, levamisole, thalidomide, and anti-vascular endothelial growth factor. In the intra-laboratory pre-validation, the sensitivity of the assay (upper and lower limits of detection and linearity of response in tubule formation), batch to batch variation in tubule formation between different Master cell bank batches, and precision as well as the reliability of the assay (reproducibility and repeatability) were tested. The pre-set acceptance criteria for the intra-laboratory pre-validation study were met. The relevance of the assay in man was investigated by comparing the effects of reference chemicals and their concentrations to the published human data. The comparison showed a good concordance, which indicates that this human cell based angiogenesis model predicts well the effects in man and has the potential to be used to supplement and/or replace of animal tests.

Objective: To assess the rate of maternal complications related to cesarean section (CS) and to compare morbidity between elective, emergency and crash-emergency CS. To establish risk factors associated with maternal CS morbidity., Design: A prospective multicenter cohort study., Setting: Twelve delivery units in Finland., Population: Women delivering by CS (n = 2,496) during a 6 months period in the study hospitals., Methods: Data on pregnant women, CS, and maternal recovery during the hospital stay was collected prospectively on report forms. The complication rates by different CSs were calculated, and factors associated with morbidity were analyzed by odds ratios (OR)., Main Outcome Measures: Maternal complication rates in different types of CS. The association of risk factors with morbidity., Results: About 27% of women delivering by CS had complications; 10% had severe complications. The complication rate was higher in emergency CS than in elective CS, and highest in crash-emergency CS. Significant independent risk factors for maternal morbidity were emergency CS and crash-emergency CS compared to elective CS (OR 1.8; 95% confidence interval (CI) 1.5-2.2), pre-eclampsia (OR 1.5; CI 1.1-2.0), maternal obesity (OR 1.4; CI 1.1-1.8) and maternal increasing age (OR 1.1; CI 1.03-1.2 per each 5 years)., Conclusions: Maternal complications are frequent in CS, and although performing CS electively reduces the occurrence of complications, the frequency is still high. The complication rate depends on the degree of emergency, and increases with maternal obesity, older age and pre-eclampsia.

Deficiencies of urea cycle enzymes are rare metabolic disorders. Inadequate function of these enzymes may in worst cases lead to hyperammonemic encephalopathy and death. The danger of urea cycle enzyme deficiencies is that previously healthy adults with no prior medical history suggesting these deficiencies may suddenly develop life-threatening complications during prolonged catabolic situations such as delivery or surgery. Since most of the metabolic disorders are diagnosed during childhood, it may sometimes be difficult to bear in mind these rare diseases as a cause of unconsciousness in adulthood. However, early diagnosis and prompt initiation of ammonia-lowering treatment are essential for survival of these patients. We present two pregnant women with urea cycle disorders: one with a known deficiency and an uncomplicated outcome, and another with a previously undiagnosed disorder and life-threatening course of the postpartum period.

The sensitivity of photoacoustic spectroscopy was improved with the invention of optical cantilever detection (PAS-OCD). However, the ability of present PAS-OCD devices to carry out multicomponent detection is poor. To overcome this, a Fourier transform infrared photoacoustic spectrometer with optical cantilever detection (FT-IR-PAS-OCD) prototype was assembled. In this article, the first evaluation and performance tests of the prototype are described. Selectivity, sensitivity, and the linearity of the signal response are evaluated. The linear response was studied for methane and carbon dioxide and confirmed in the whole analyzed concentration range from 500 to 3500 ppm and from 2500 to 17500 ppm, respectively. The calculated signal-to-noise ratio (SNR) and limit of detection were 2027 and 0.5 ppm for methane and 1362 and 4 ppm for carbon dioxide, with a measurement time of 100 seconds. Selectivity was studied with a multicomponent gas mixture of propene, methane, carbon dioxide, and methylmercaptane. The results indicate that a quantitative analysis of all components in the mixture is possible using the FT-IR-PAS-OCD.

Postpartum embolization to decrease the maternal mortality rate and postpartum hysterectomies. An interventional radiologist performs the embolization at the obstetrician's request, when conventional means have failed to stop the bleeding. This will efficiently stop the bleeding. Fertility appears to remain normal after embolization. Embolization of uterine arteries is also utilized for the treatment of symptomatic myomas in patients, who do not wish to become pregnant. After the embolization the myomas will gradually shrink within months. The procedure has been found to be safe.

Five to six percent of babies are born preterm (before completed 37 weeks of pregnancy) in Finland. Efforts should be made to recognize those patients at greatest risk for preterm labour. Before possible attempts of tocolytic therapy fetal distress, true labour or manifest infection should be ruled out. The prognosis of preterm infants can be improved by concentrating very preterm births (before 30 weeks) to tertiary hospitals, giving antenatal corticosteroid therapy, diagnosing subclinical infection and timing the deliveries in order not to dispose the fetus to prolonged inflammation.

A photoacoustic detector based on the optical cantilever microphone has been built. The detector is capable of measuring solid-, liquid-, and gas-phase samples. Photoacoustic Fourier transform infrared (FT-IR) measurement with three samples in different phases was demonstrated. Example samples were polyethene, sunflower oil, and methane. The sensitivity of the cell was compared to a commercial photoacoustic FT-IR detector. With the standard carbon black sample the cantilever detector gave approximately five times higher signal-to-noise ratio than the reference detector. The sensitivity with methane was also compared to the DTGS detector of the FT-IR instrument corresponding to an absorption path of 6.3 cm. Simulation of the photoacoustic signal showed that a compromise has to be made in the cell design between sensitivity for solid- and gas-phase samples but it is possible to highly enhance the sensitivity for all types of samples by reducing cantilever dimensions.

Our objective was to describe the clinical outcome and the association of fetomaternal platelet immunization in pregnancies with maternal Bernard-Soulier syndrome. We conducted an observational study of two mothers, six pregnancies, and six neonates, with special emphasis on platelet antibodies and thrombocytopenia-associated complications. The first woman presented with platelet-associated autoantibodies and thrombocytopenia, but her three newborn infants showed normal platelet count and function. The other woman had three pregnancies, all of which were complicated by severe fetal and neonatal alloimmune-type thrombocytopenia, without demonstrable antibodies. We concluded that fetomaternal immunization with severe fetal and neonatal thrombocytopenia may be encountered even in the absence of demonstrable antibodies.

To evaluate obstetric predictors of umbilical cord plasma AVP levels, serum TSH levels and the timing of first voiding, 87 singleton term newborns were divided into three groups: group A, vaginal delivery (n = 30); group B, cesarean section (CS) during labor (n = 26); and group C, elective CS (n = 31). The AVP concentration was 120 (0.7-2170) ng/L in group A, 1.8 (0.01-183) ng/L in group B, and 0.8 (0.01-30) ng/L in group C (p < 0.001). In group A, the TSH concentration was 10.20 (3.5-30.80) mU/L; in group B, 5.40 (2.10-43.00) mU/L; and in group C, 5.30 (2.90-11.00) mU/L (p = 0.001). Duration of labor had a positive correlation with AVP (p < 0.001) and TSH (p = 0.001) concentrations. The timing of first voiding had a positive correlation with gestational age (p = 0.003), volume of additional feeding before first voiding (p < 0.001), and umbilical AVP concentration (p = 0.023). The AVP and TSH concentrations are associated with mode of delivery and duration of labor and AVP levels also with the timing of first voiding in the newborn.

Objective: To assess hemodynamic and NT-proANP changes in women with chronic hypertension during pregnancy., Methods: Stroke volume index (SI), heart rate (HR), cardiac output index (CI), systemic vascular resistance index (SVRI), pulse wave velocity (PWV), and left cardiac work index (LCWI) were measured using whole-body impedance cardiography. Systolic blood pressure (SAP), mean arterial pressure (MAP), diastolic blood pressure (DAP), and pulse pressure (PP) were also measured. Arterial compliance was defined as the SI-to-PP ratio (SI/PP). Hemodynamic parameters and NT-proANP concentrations were assessed during the early and late second trimester, the third trimester, and after delivery in 20 women with essential hypertension and 30 normotensive women., Results: Arterial blood pressure, SVRI, and PWV remained higher during the whole study period in chronic hypertensive compared with healthy pregnancies. In the early second trimester, women with chronic hypertension had significantly lower SI and NT-proANP concentrations than did normotensive women., Conclusion: The hemodynamics of chronic hypertension during pregnancy are characterized by persistent high vascular resistance. Lower SI and NT-proANP values found in chronic hypertensive pregnancies during the early second trimester may suggest a reduced intravascular volume increase during pregnancy.

Objective: To determine how pre-eclampsia modifies maternal haemodynamics during caesarean delivery., Design: Prospective study., Setting: Tampere University Hospital, Finland., Population: Ten pre-eclamptic parturients and ten healthy parturients with uncomplicated pregnancies scheduled for elective caesarean section under spinal anaesthesia., Methods: Haemodynamic parameters were assessed by whole-body impedance cardiography noninvasively., Main Outcome Measures: Stroke index (SI), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI) and mean arterial pressure (MAP) were recorded before operation, continuously during caesarean section, during the period of dissipation of anaesthesia and on the second to fifth postpartum day., Results: Baseline haemodynamics in women with pre-eclampsia differed significantly from healthy women in higher SVRI and MAP and lower SI and CI. In women with pre-eclampsia, preload infusion increased both SI and HR, causing a significant rise in CI, while in healthy parturients, only HR rose. In both the groups, spinal blockade reduced SVRI but CI remained stable. At the moment of delivery, CI increased in both groups. In uncomplicated pregnancies, both SI and HR increased, but in women with pre-eclampsia, SI was not altered and the rise in CI was due to an increase in HR only. After the reversal of anaesthesia, haemodynamics in the control group returned to baseline values, whereas in women with pre-eclampsia, SI and CI fell to levels that were significantly lower than the levels observed before surgery., Conclusions: In women with pre-eclampsia, inability to increase SI at the moment of delivery may suggest dysfunction of the left ventricle to adapt to volume load caused by delivery and prompts concern for the increased risk of pulmonary oedema.

Objective: To compare the combination of intravenous propranolol and oxytocin with oxytocin only in augmentation of labour., Study Design: A prospective randomized double-blind study in an obstetric department of a large university hospital in Finland. A total of 107 parturients with arrested first stage of labour owing to inadequate uterine contractility were randomized to receive intravenously once or twice a 2 mg dose of propranolol or placebo combined with oxytocin infusion. The main outcome measure was the effect of intravenous propranolol on the frequency of Caesarean section among parturients with arrested labour. The secondary outcome measures were the duration of labour, the required dosage of oxytocin, CTG readings, neonatal outcome and maternal and cord plasma levels of beta-adrenoceptor-binding component of propranolol. Categorial variables between the groups were compared using Chi square and Fisher's exact tests. Continuous variables were compared using the Mann-Whitney U-test and Student's t-test., Results: No reduction in Caesarean section rate was found in the propranolol group. Seventy-three percent of the parturients in the propranolol group and 85% in the placebo group had spontaneous vaginal delivery, RR=0.86 (95% CI 0.70-1.05). The percentage proportion of the augmented part of labour was significantly shorter in the propranolol group than in the placebo group. No differences in the required oxytocin dosage or CTG pathology were found between the groups. Propranolol was found to be safe for the neonates. The concentrations of its beta-adrenoceptor-binding component after a 2mg intravenous dose were quite similar in parturients and neonates at the time of delivery. The active drug component crossed placental barriers with an average neonate umbilical artery/parturient venous plasma ratio of 0.7. After a 4 mg dose the active drug concentrations in parturients were rather similar to those measured after 2 mg dose, whereas in neonates there were signs of drug accumulation. No picture could be obtained from the kinetics of the beta-adrenoceptor-binding component of propranolol from the data., Conclusions: Propranolol (2 or 4 mg i.v.) combined with oxytocin, as treatment for arrested labour did not affect the Caesarean section rate compared with placebo plus oxytocin. The percentage proportion of the augmented part of labour was significantly shorter after propranolol. Propranolol was safe for the neonates and can be used as an additional medication among parturients with arrested labour.

Predictors of tubular proteinuria (alpha 1-M/crea ratio >10 mg/mmol) were sought in 100 infants of 24-32 weeks' (group 1) and 69 of 34-42 weeks' gestation (group 2). Random spot urine samples were obtained in the former group at the ages of 0-3 days, at 1-2 weeks and thereafter at 2-week intervals until the disappearance of tubular proteinuria, and in the latter one sample at a mean (SD) of 3.0 days' (1.3) age. In group 1, gestational age correlated negatively with the first urinary alpha 1-M/crea ratio. The highest urinary alpha 1-M/crea ratios [median (range) 39.1 mg/mmol (9.5-268.9)] occurred at a median (range) of 5 days' (1-42) age. Low gestational age and the need for inotropes predicted tubular proteinuria early after birth, whereas low gestation and long duration of ventilator treatment predicted the highest alpha 1-M/crea ratios. Prolonged vancomycin treatment and low gestational age were associated with delayed normalization of tubular proteinuria. In group 2 no significant risk factors for tubular proteinuria were found. The urinary alpha 1-M/crea ratio seems to be a sensitive indicator of renal tubular function in neonates, with low gestational age, the need for inotropes and prolonged assisted ventilation being predictors of increased tubular proteinuria. Long vancomycin courses should be avoided in pre-term infants in view of the prolonged adverse renal effects.

Background and Aim: To compare perinatal outcome in groups of planned vaginal breech delivery, elective cesarean section with the fetus in breech presentation, and planned vaginal delivery with the fetus in cephalic presentation in a university hospital with a tradition of managing breech deliveries by the vaginal route., Methods: A cohort study from a 7-year period 1995-2002, including 590 planned vaginal deliveries with a term (> 37 weeks) singleton fetus in breech presentation, 396 elective cesarean sections with a term singleton fetus in breech presentation, and 590 control women intending vaginal delivery with a singleton term fetus in cephalic presentation., Results: The Apgar scores were lower in the group of planned vaginal breech delivery, but in other outcome measures there were no significant intergroup differences. The overall neonatal morbidity was small (1.2% vs. 0.5% vs. 0.3% in the respective study groups) if compared to a recently published randomized multicenter study., Conclusions: Selective vaginal breech deliveries may be safely undertaken in units having a tradition of vaginal breech deliveries.

Background: This descriptive study was designed to evaluate maternal hemodynamics and cardiovascular responses to delivery during cesarean section (CS) under spinal anesthesia. We also assessed the feasibility of a noninvasive and continuous method of measuring cardiac output, namely whole-body impedance cardiography (ICG(WB)), during elective CS. Because of the techniques used in previous studies, only fractionated data on maternal hemodynamics during CS are available to date., Methods: We studied 10 healthy women with normal pregnancies and two pregnant women with heart disease undergoing elective CS. Mean arterial pressure (MAP), heart rate (HR), stroke index (SI), cardiac index (CI) and systemic vascular resistance index (SVRI) were recorded continuously during CS, during the period of dissipation of anesthesia and on the second to fifth postpartum day. Analysis of variance for repeated measurements (anova) and the paired sample t-test were used in statistical analysis., Results: The hemodynamic parameters could be registered continuously during the whole procedure. At the point of delivery, a 47% increase in CI and a 39% decrease in SVRI were recorded, while MAP remained stable. These changes occurred within 2 min of delivery of the newborn and persisted on average for 10 min., Conclusion: Sudden and significant hemodynamic changes take place at the moment of delivery. Intact physiological cardiovascular compensation mechanisms are needed to adapt to these challenges. Whole-body impedance cardiography may offer a useful noninvasive tool to monitor hemodynamics during cesarean section.

We present a pregnancy complicated by multicystic dilatation of the uterine wall during the second trimester, leading to massive uterine distension, anemia and preterm Cesarean section. The cystic changes detected by ultrasound and magnetic resonance imaging involved the whole uterine wall surrounding the entire amniotic cavity. Histopathological examination revealed the benign nature of the cystic changes, which represented dilated and thrombosed venous lacunae. Disturbed venous drainage, combined with local thrombosis, was likely to have led to the collection of a large volume of blood in the uterine wall and the subsequent multicystic change of the myometrium., (Copyright 2004 ISUOG)

We analyzed surveillance data on group B streptococcus (GBS) infection in Finland from 1995 to 2000 and reviewed neonatal cases of early-onset GBS infection in selected hospitals in 1999 to 2000. From 1995 to 2000, 853 cases were reported (annual incidence 2.2-3.0/100,000 population). We found 32-38 neonatal cases of early-onset GBS disease per year (annual incidence 0.6-0.7/1,000 live births). In five hospitals, 35% of 26 neonatal cases of early-onset GBS infection had at least one risk factor: prolonged rupture of membranes, preterm delivery, or intrapartum fever. Five of eight mothers screened for GBS were colonized. In one case, disease developed despite intrapartum chemoprophylaxis. Although the incidence of early-onset GBS disease in Finland is relatively low, some geographic variation exists, and current prevention practices are suboptimal. Establishing national guidelines to prevent perinatal GBS is likely to reduce the incidence of the disease.