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Objective To investigate if the humerospinous distance, as an indicator of shoulder width, could predict shoulder dystocia at term. Design Prospective cross-sectional study of a stratified reference group of healthy women and a test group of women with risk factors for shoulder dystocia. Measurements were not revealed. Outcome measures were difficulties with delivery of the shoulders and correlation with maternal body mass and birth weight. Subjects Seventy-two women with singleton pregnancies at a University Clinic: 32 women at 39–42 weeks for reference and 40 women in an at-risk test group (weight > 90 kg, weight gain > 20 kg, previous macrosomic baby, history of shoulder dystocia/difficult delivery, clinical suspicion of a large baby). Women with a breech fetus, twins and those not able to deliver vsaginally were excluded. Methods Fetal shoulders were measured from the convergence of the cervical spinous processes at the approximate cervicothoracic vertebral junction to the medial border of the humeral head. Correlations were made with maternal body mass, birth weight, birth weight estimation, ultrasound and postnatal humerospinous measurements. Results One case of shoulder dystocia in a fetus with an average humerospinous measurement occurred in the reference group and there were no cases in the test group. There was no predictive value of a large humerospinous measurement and no correlation with maternal or fetal size. Movement of the fetal arm could change the humerospinous distance considerably, which could account for the difference between a normal and large measurement. Conclusion The humerospinous distance cannot be used to predict shoulder dystocia. Copyright © 1998 International Society of Ultrasound in Obstetrics and Gynecology

Background. Urinary incontinence and urinary tract infection are common problems among elderly women due to age-related changes in the urogenital tract, but information regarding prevalence and presentation among the aged is limited.Methods. A total of 97 randomly selected women aged 80-89 years, 47 living in homes for the elderly and 50 living at home, were asked about urogenital complaints in a structured interview. Medical records provided information about urinary tract infections and the use of estrogens.Results. Urinary incontinence affected 46%; half of them daily. Urge incontinence was most common (43%), then mixed incontinence (28%) and stress incontinence (26%). Urge and mixed incontinence caused significantly more discomfort than stress incontinence. During the past two years 33% of the women had experienced urinary tract infection and 11% had =5 infections. A total of 22 women were receiving estrogen treatment, more often in homes for the elderly (p

SummaryPregnancy-induced hypertension may be regarded as a manifestation of endothelial-cell dysfunction. The role of the eNOS gene in the development of a familial pregnancy-induced hypertension was evaluated by analysis of linkage among affected sisters and in multiplex families (n = 50). Markers from a 4-cM region encoding the eNOS gene showed distortion from the expected allele sharing among affected sisters (P = .001−.05), and the statistic obtained from the multilocus application of the affected-pedigree-member method also showed distortion (T[f(P) = sqrt(P)] = 3.53; P < .001). A LOD score of 3.36 was obtained for D7S505 when a best-fitting model derived from genetic epidemiological data was used, and LOD scores of 2.54–4.03 were obtained when various other genetic models were used. Estimates of recombination rate, rather than maximum LOD-score values, were affected by changes in the genetic parameters. The transmission-disequilibrium test, a model-free estimate of linkage, showed strongest association and linkage with a microsatellite within intron 13 of the eNOS gene (P = .005). These results support the localization of a familial pregnancy-induced hypertension—susceptibility locus in the region of chromosome 7q36 encoding the eNOS gene.

Postpartum hemorrhage (PPH) is still the most importantand potentially avoidable cause of maternal death (1). Theuterus in late pregnancy or at term has at any moment athrough-flow of blood that corresponds to approximatelyone-sixth of the pregnant woman’s total blood volume, set-ting the scene for massive bleeding from up to 200 dilatedspiral arteries into the uterine cavity, if the uterus does notretract and contract as expected. Hemorrhage ensues, whichin a short time may lead to death of a woman in the primeof her life – death at a time when she is supposed to behealthy and able to tolerate more than at other ages. Therapidity of blood loss often goes unnoticed until the situationstarts to deteriorate. If the patient is weak and anemic likemany women are in low-resource countries, if she is poorlynourished as may easily be seen in the supposedly richersocieties, or if she is in the wrong type of delivery situationwhere background services and transport are inadequate, thedanger of severe morbidity and even death is real. There aregood reasons why the overwhelming numbers of maternaldeaths from severe PPH have stimulated initiatives fromregional and international organizations to try to prevent andlimit the serious effects of postpartum hemorrhage.Clinical improvement activities have mainly focused onmedical treatment of uterine atony. In 2003 at the FIGO con-ference in Santiago, Chile, the two professional organizationsFIGO (International Federation of Gynecology andObststerics) and the ICM (International Confederation ofMidwives) launched a global initiative to combat maternaldeath from PPH (2,3). Since there was evidence that activemanagement of the third stage reduced the incidence of PPH,the quantity of blood loss and the use of blood transfusion,the two organizations agreed that active management of thethird stage should be offered to all women. This involvedadministration of uterotonic drugs, controlled cord tractionand uterine massage following delivery of the placenta.However, the retained placenta and abnormally invasiveplacenta (AIP) present a different problem where uterineatony may persist along with incomplete separation and thuscontinued bleeding from a varying and always unknownnumber of large vessels in the placental bed. The most com-mon form of a retained placenta may not respond effectivelyto medical treatment and after a while result in atony andbleeding. Which is the best approach to the common retainedplacenta? For how long should we wait before proceeding tomanual evacuation? Giel van Stralen and colleagues in Leiden,Amsterdam and Den Haag, Netherlands (pp. 396–402), SysNikolajsen and co-workers in Hillerod, Denmark (pp. 419–423)and Vedran Stefanovic and colleagues in Helsinki, Finland(pp. 424–431) present new data on the clinical managementof retained placenta with different results and conclusions.Therefore, and for the paucity of evidence-based literature onthis topic, we aim to call for large observational and random-ized controlled studies on retained placenta and PPH. Oneexample is the postpartum use of ultrasound when there is aretained placenta. Can ultrasound be used to differ betweenan entrapped placenta that should be removed manually andAIP, where a quite different management approach is needed?After studying this issue of AOGS, you will agree that this ispossible. Furthermore, the prenatal suspicion of AIP isimportant because that alone will reduce the maternalmorbidity, as reported by Frederic Chantraine and a consor-tium of co-workers in Belgium, Germany and Switzerland(pp. 437–442).Retention of bits and pieces of the placenta or membranesmay result in atony, which initially is somewhat responsive touterotonics, but where hemorrhage will eventually recur in asituation when the mother is lactating, enjoying her first mealand the family is celebrating. Therefore, the management forPPH starts with a clinical examination (inspection of vulva,vagina and cervix) and exploration of the uterine cavity,either by manual revision or ultrasound. In addition to themedical treatment, Bakri balloon tamponade must also beconsidered as a rapid and effective option where applicable.The results presented by Maiju Gr€onvall and co-workers inHelsinki, Finland (pp. 431–436) and Laura Aibar and col-leagues in Granada and Motril, Spain (pp. 463–465), areencouraging.All women with retained placenta do potentially need anes-thesia. These women need to be prioritized because an unnec-essary delay will inevitably result in more blood loss (4). Closecollaboration with a view “to make plans” in a team formedby obstetricians, anesthetists and midwives is necessary forthese situations. Practical consideration of all eventualities isessential since the quantity of PPH is very time dependent. In

(2004). No link between low‐grade periodontal disease and preterm birth: a pilot study in a healthy Caucasian population. Acta Odontologica Scandinavica: Vol. 62, No. 3, pp. 177-179.

Evidence about the influence of hypertension in pregnancy on later health and in particular the risk of cardiovascular disorders is conflicting, although a link has been suggested. In a population-based study with a long follow-up time the potential association between hypertension in pregnancy, preeclampsia and eclampsia with increased death rates from ischemic heart disease (IHD) was investigated.All 7543 case records at the main maternity hospital in Iceland during 1931-1947 were reviewed to identify women with hypertension in pregnancy, subdivided by parity and severity of disease into those with eclampsia, preeclampsia and hypertension alone. Information on those who had died was obtained from death certificates, supplemented by autopsy reports and hospital records. Death rates from IHD were compared to population data from public health and census reports during corresponding periods and between study groups.Of 374 hypertensive women 177 had died. The death rate was slightly higher among women with any hypertension in pregnancy than in the reference population (RR = 1.20; 95% CI 1.01-1.42). About half of the increase was attributed to excess mortality from IHD with a relative risk of dying of 1.47 (95% CI 1.05-2.02). The relative risk of dying from IHD was significantly higher among eclamptic women (RR = 2.61; 95% CI 1.11-6.12) and those with preeclampsia (RR = 1.90; 95% CI 1.02-3.52) than those with hypertension alone. Parous women at the index pregnancy had a twofold higher risk of dying from IHD than primigravid women (RR = 2.05; 95% CI 1.19-3.55; p = 0.01).There is an indication of increased death rates among women with a history of hypertension in pregnancy, where ischemic heart disease may be more common than in the general population.

Objective: To investigate how well various inheritance models would explain the familial tendency of the preeclampsia/eclampsia syndrome.Methods: The prevalence among seven groups of women with definite probabilities of exhibiting the disorder from six different family studies was used to obtain maximum likelihood estimates of the contributions to disease liability from major genes and multifactorial transmission.Results: Models involving a single major gene with incomplete penetrance or multifactorial inheritance offered considerably better fit to the observed data than no familial transmission at all or autosomal dominant and recessive inheritance models with complete penetrance. Of the major gene models, a dominant mode of transmission was preferred. From the extremes of the joint 95% confidence region for the gene frequency (p) and penetrance (f), the corresponding confidence limits for the best estimates were 0.06 f > 0.23, respectively.Conclusions: These results indicate that t...

To investigate linkage between the renin gene restriction fragment length polymorphisms in families with a history of preeclampsia/eclampsia.Nine Icelandic families with at least three affected females in two or three generations were investigated. DNA from lymphocytes was digested with the endonuclease restriction enzyme Bgl I and restriction fragments were transferred by Southern Blotting. Hybridisation was effected with the 32P-oligonucleotide-labeled diallelic genomic probe pHRnX 0.8. LOD scores were calculated by the Liped program for two forms of inheritance patterns. Affected sib pairs were analysed.Frequencies of the 9.0 kb and 5.0 kb alleles were 0.67 and 0.33, with no significant differences between affected females and spouses and combined LOD scores of -2 for recombination values of 3%. Allele sharing in affected sibs was not different from the expected random assortment.The linkage analysis provides evidence to exclude alteration of the renin gene in pregnancy as being directly responsible for the manifestations of preeclampsia or eclampsia in these families.

Objective We estimated the risk of complications at birth of extremely large babies (≥5000 g). Study Design This was a cohort study including all births of extremely large babies in 1996 through 2005 and comparison cohort with normal birthweight (1:2) identified in the national birth registration. Results There were 343 extremely large babies or 0.9% of all singletons. Compared to the normal birthweight cohort (n = 679), there were increased odds of shoulder dystocia (odds ratio [OR], 26.9; 95% confidence interval [CI], 11.1–65.1), emergency cesarean section (OR, 5.2; 95% CI, 3.4–8.0), and failed labor induction (OR, 4.3; 95% CI, 1.7–11.0). The risk of elective section was not increased (OR, 1.1; 95% CI, 0.6–2.0). Minor congenital malformations were more frequent (OR, 2.1; 95% CI, 1.2–3.7), as were birth injuries (OR, 3.7; 95% CI, 2.1–6.8) and minor metabolic disturbance (OR, 2.5; 95% CI, 1.1–6.2), but not asphyxial births. Conclusion The risk of shoulder dystocia for very large babies is markedly raised, as are minor complications, while for mothers the main risk is emergency section.

The annual incidence of pelvic endometriosis among women aged 15-49 years and up to age 69 years was ascertained for the Icelandic population between 1981 and 2000 by using Iceland's extensive record linkage systems. Comprehensive, state-financed health care and unique personal identification numbers enabled care to be tracked from first diagnosis. To identify cases, a centralized discharge-code registry was searched, as well as all hospital databases and, for individual patients, all hospital records. Each case of visually diagnosed and histologically verified endometriosis was cross-checked against the nationwide pathology registry. The revised American Society for Reproductive Medicine classification system was used for staging. Recorded was type of operation at diagnosis and presence of disease at 5 sites: deep pelvis, appendages, central pelvis, vesicouterine pouch, and ovaries. A total of 1,383 women were diagnosed surgically, with histologic verification of 811 (58.6%). All but 6 cases could be staged; 297 (36.9%) had minimal/mild and 508 (63.1%) had moderate/severe disease. The estimates of crude annual incidence were 0.1% for visually confirmed and 0.06% for histologically verified endometriosis, and respective age-standardized annual incidence was 0.1% and 0.05% for women aged 15-49 years. The most common site was the ovary, followed by deep pelvis, central pelvis, appendages, and vesicouterine pouch.

Use of the levonorgestrel emergency contraception (EC) pill has become more common after being made formally available in pharmacies without prescription. It was investigated how pharmacists in the capital area of Reykjavik supply EC to clients.A total of 46 pharmacists of all working ages and both genders were asked to answer a questionnaire concerning how they sold the emergency contraception pill over the counter (84.8% reply rate).Four of five used5 minutes to discuss emergency contraception with the client, but almost all enquired about time from intercourse. While only 20% asked about the woman s health, most considered concomitant drug use and potential interaction with levonorgestrel. Only about 50% pointed out that EC did not protect against sexually transmitted disease, (3/4) pointed out the need for permanent contraceptive use, 95% asked about previous EC use, but only 30% would provide EC again in the same menstrual cycle. One half of the pharmacists sold EC to men/teenage boys and wished to assist them with taking responsibility, while the others only sold the drug to the woman. Of those prepared to give the drug to the men, 55% asked to speak over the telephone with the woman to ensure correct prescription and information. Nearly a third would never or rarely provide consultation in private.Pharmacists agree mostly about main points in supplying EC, but not as regards provision to women through their male partners. Provisons for consultation can be improved.

A rising cesarean section rate has been suggested as of benefit in reducing the already low perinatal death rates seen in developed countries for infants of normal birthweight. Iceland has one of the lowest national corrected and uncorrected perinatal mortality rates. Information was collected through the Icelandic birth registry for all 82,251 deliveries of non-malformed singletons weighingor = 2,500 g at birth, for the 20 years 1987-2006. The mean birthweight-specific perinatal mortality rate for these pregnancies was 2.0/1,000 per year (range 0.8-4.1/1000) without significant changes over the study period. The cesarean section rate varied between 11.9 and 16.7% and did not correlate with the perinatal mortality rate. Among the nulliparous women, cesarean section rates increased from 13.1 to 17.9% without correlation to the perinatal mortality, which on average was 1.7/1,000. A further benefit from rising cesarean section rates at term in countries with a prior low perinatal mortality is questioned.

To investigate the association between menstrual flow weight measured from modern sanitary pads (converting liquid to non-evaporating gel) and clinically assessed normal, increased or decreased menstrual flow.Objective method development study.Outpatient clinic, University Hospital, Reykjavik.One hundred and thirteen volunteers included 26 normally menstruating adult women and 52 normally menstruating teenagers not using oral or intrauterine contraception, seven normally menstruating women using oral contraception, 17 women with clinically diagnosed menorrhagia, five women using oral contraception for clinical menorrhagia, and six teenage girls claiming heavy menstrual flow.Menstruation length, menstrual flow weight and history of iron deficiency were assessed. During the menstruation following recruitment, all women collected their used protective pads in a hygienic manner and returned them to the laboratory for accurate weighing.Menstrual flow total weight measured in grams.Mean menstrual flow total weight in the 78 asymptomatic women was 51 g (median 44, range 5-144). The mean flow in 17 women clinically diagnosed with menorrhagia was 217 g (median 207, range 63-402) (p0.0001 compared to healthy women). The seven healthy women using oral contraceptives discharged 13 g (13-19) (p=0.0004 compared with normals). Menstruation lastedeight days in 77/78 healthy women and in 12 of 17 clinically diagnosed menorrhagic women.Measurement of menstrual flow total weight accurately reflects clinically assessed normal, increased and decreased flow. The method is an easy and accurate way of objectively estimating menstrual flow.

Intracervical application of prostaglandin E2 (PGE2) in a viscous gel was compared with conventional wax-based PGE2 vagitories (pessaries) for ripening of the cervix prior to induction of labor. A total of 226 healthy pregnant women at term were randomly allocated to receive intracervical gel with an effective dose of 0.5 mg (n = 116) or vagitories containing 2.5 mg PGE2 (n = 110). All women had a modified cervical score of less than or equal to 4. The numbers of cases contributed by each of the three centers were similar. There was no significant difference in parity, gestational length, maternal characteristics, indications for induction or preinduction cervical scores between the treatment groups. The rate of spontaneous birth was 71% in the gel group, compared with 69% in the vagitory group. Successful treatment was defined as active labor within 24 h or a change in cervical dilatation allowing artificial rupture of the membranes with subsequent progressive labor. The success rate was not significantly different in the gel group (82%) compared with the vagitory group (80%). There were no differences in the frequency of fetal distress, outcome of labor, assisted delivery rates or maternal side effects. The cervical scores were not different at 12 and 24 h after application. Intracervical gel and intravaginal application of PGE2 were similar in their efficacy and safety for ripening of the cervix and inducing labor at term.