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The COVID-19 pandemic had adverse health outcomes on individuals and communities. In this cross-sectional study we evaluated the admission rates in a tertiary-level hospital during the first wave of the pandemic (March 22, 2020 to August 31, 2020).

Introduction: This study assessed prevalence and time trends of pre‐pregnancy obesity in immigrant and non‐immigrant women in Norway and explored the impact of immigrants' length of residence on pre‐pregnancy obesity prevalence. Material and Methods: Observational data from the Medical Birth Registry of Norway and Statistics Norway for the years 2016–2021 were analyzed. Immigrants were categorized by their country of birth and further grouped into seven super regions defined by the Global Burden of Disease study. Pre‐pregnancy obesity was defined as a body mass index ≥30.0 kg/m2, with exceptions for certain Asian subgroups (≥27.5 kg/m2). Statistical analysis involved linear regressions for trend analyses and log‐binomial regressions for prevalence ratios (PRs). Results: Among 275 609 pregnancies, 29.6% (N = 81 715) were to immigrant women. Overall, 13.6% were classified with pre‐pregnancy obesity: 11.7% among immigrants and 14.4% among non‐immigrants. Obesity prevalence increased in both immigrants and non‐immigrants during the study period, with an average yearly increase of 0.62% (95% confidence interval [CI]: 0.55, 0.70). Obesity prevalence was especially high in women from Pakistan, Chile, Somalia, Congo, Nigeria, Ghana, Sri Lanka, and India (20.3%–26.9%). Immigrant women from "Sub‐Saharan Africa" showed a strong association between longer residence length and higher obesity prevalence (≥11 years (23.1%) vs. <1 year (7.2%); adjusted PR = 2.40; 95% CI: 1.65–3.48), particularly in women from Kenya, Eritrea, and Congo. Conclusions: Prevalence of maternal pre‐pregnancy obesity increased in both immigrant and non‐immigrant women from 2016 to 2021. Several immigrant subgroups displayed a considerably elevated obesity prevalence, placing them at high risk for adverse obesity‐related pregnancy outcomes. Particular attention should be directed towards women from "Sub‐Saharan Africa", as their obesity prevalence more than doubled with longer residence. [ABSTRACT FROM AUTHOR]

There is little documented evidence regarding the practice of midwives providing care for women with acute concerns in early pregnancy (< 20 weeks) in Australia. Women can experience unexpected complications at any gestation of pregnancy and may seek acute care in an emergency or gynaecology service, usually staffed by registered nurses (RNs). They may not receive care from specialised pregnancy clinicians, including midwives. The role and scope of practice of midwives working in acute early pregnancy settings in Australia has not been previously reported. This study provides an opportunity to document practice in an area of pregnancy care not often visible within maternity services in Australia. To describe midwives' and RNs perceptions, perspectives and experiences of role and scope of practice in acute early pregnancy care provision in Australia. A qualitative descriptive approach was adopted. Midwives and RNs with acute early pregnancy knowledge and experience were recruited. Semi-structured interviews were conducted, and data analysed using inductive thematic analysis. Fifteen participants were interviewed. Three themes were constructed from interview data: Personal and Professional Influences; Being There for Women; The Impact of Setting. Findings reinforce the lack of clarity around how midwives' scope is enabled in traditional acute early pregnancy care. Setting of care has influenced practice and seen a barrier for midwives who don't hold nursing registration from fulfilling professional scope. Results provide novel benchmarking evidence regarding a largely hidden area of midwifery, signposting areas for reform within education, policy and health service sectors. [ABSTRACT FROM AUTHOR]

Introduction: There is no global agreement on how to best determine pregnancy of unknown location viability and location using biomarkers. Measurements of progesterone and β human chorionic gonadotropin (βhCG) are still used in clinical practice to exclude the possibility of a viable intrauterine pregnancy (VIUP). We evaluate the predictive value of progesterone, βhCG, and βhCG ratio cut‐off levels to exclude a VIUP in women with a pregnancy of unknown location. Material and methods: This was a secondary analysis of prospective multicenter study data of consecutive women with a pregnancy of unknown location between January 2015 and 2017 collected from dedicated early pregnancy assessment units of eight hospitals. Single progesterone and serial βhCG measurements were taken. Women were followed up until final pregnancy outcome between 11 and 14 weeks of gestation was confirmed using transvaginal ultrasonography: (1) VIUP, (2) non‐viable intrauterine pregnancy or failed pregnancy of unknown location, and (3) ectopic pregnancy or persisting pregnancy of unknown location. The predictive value of cut‐off levels for ruling out VIUP were evaluated across a range of values likely to be encountered clinically for progesterone, βhCG, and βhCG ratio. Results: Data from 2507 of 3272 (76.6%) women were suitable for analysis. All had data for βhCG levels, 2248 (89.7%) had progesterone levels, and 1809 (72.2%) had βhCG ratio. The likelihood of viability falls with the progesterone level. Although the median progesterone level associated with viability was 59 nmol/L, VIUP were identified with levels as low as 5 nmol/L. No single βhCG cut‐off reliably ruled out the presence of viability with certainty, even when the level was more than 3000 IU/L, there were 39/358 (11%) women who had a VIUP. The probability of viability decreases with the βhCG ratio. Although the median βhCG ratio associated with viability was 2.26, VIUP were identified with ratios as low as 1.02. A progesterone level below 2 nmol/L and βhCG ratio below 0.87 were unlikely to be associated with viability but were not definitive when considering multiple imputation. Conclusions: Cut‐off levels for βhCG, βhCG ratio, and progesterone are not safe to be used clinically to exclude viability in early pregnancy. Although βhCG ratio and progesterone have slightly better performance in comparison, single βhCG used in this manner is highly unreliable. [ABSTRACT FROM AUTHOR]

Aim: To examine whether there are differences in the vaginal microbiome of women who miscarry compared to those who have normal pregnancy outcomes. Methods: Prospective observational study conducted at the Canberra Hospital, Australia, with 24 participant women in the first trimester of pregnancy. The vaginal microbiomes of the 24 women were characterized using sequencing analysis of the V4 region of the 16S rRNA gene employing an Illumina MiSeq instrument with QIAGEN reagents. Vaginal microbiome data were correlated with pregnancy clinical metadata. Results: Ordination plots showed differences in the composition of microbiomes of women who miscarried and controls. In nulliparous women, Lactobacillus crispatus was the dominant bacterium in 50% of women. Lactobacillus iners was the dominant bacterium in 50% of women with a history of prior miscarriage and a miscarriage in the study compared to 15% (p = 0.011) in those with no history of miscarriage and no miscarriage in the study. There were significant differences in the number of operational taxonomic units and the richness of the microbiomes of women who miscarried compared to those who delivered at term. Eight taxa were found in different relative abundances in both groups of women. Conclusions: The study indicated that the composition of the vaginal microbiome varies with pregnancy history. Also, there was a significant difference in the vaginal microbiomes between women who suffered miscarriage and those who continued to term delivery both in the overall microbiome populations and in the abundances of individual taxa. [ABSTRACT FROM AUTHOR]

Objective: To evaluate longitudinal changes of angiogenic biomarkers in early- (EO-PD) versus late-onset (LO-PD) placental dysfunction. Methods: Serum PlGF and sFlt-1 measured at different intervals in EO-PD (n= 43), LO-PD (n= 31) and controls (n = 133). Results: sFlt-1/PlGF ratio was higher at 16 weeks (30.6 vs 17.5), 20 weeks (29.3 vs 8.9) and 30 weeks (16.6 vs 6.7) in EO-PD vs controls (all p< 0.05), but not in LO-PD. Longitudinal changes for all intervals had higher AUC than single measurements. Conclusion: Longitudinal biomarker change between 12 and 30 weeks could improve prediction of EO-PD compared to single measurements.

Introduction: Biological rhythms, the innate cycle of changes in the body's physiological functions, are circadian if they have a 24‐hour period. It is known that sleep is a key feature of human circadian rhythm but the relation between sleep and female fertility is largely unknown. This paucity of research is surprising given that circadian rhythms are paramount to human physiology and sleep is related to major female reproductive events. This study was designed to investigate whether there is a difference between the sleep and activity parameters of women with poor reproductive outcome compared with healthy, fertile parous women (comparator group) using subjective (questionnaires) and objective (actigraphy and light exposure) measures. Material and methods: A prospective cohort study in a tertiary in vitro fertilization referral center in the UK; composed of three study groups: women diagnosed with recurrent implantation failure, women with recurrent miscarriage (RM) and a comparison group (fertile women without endometrial pathology). Comparison women were selected gynecology patients without endometrial disease (ie perineal complaints or altruistic egg donors). Primary outcome was differences in objective length of sleep in each of the participant groups using actigraphy. Secondary outcomes were subjective sleep quality and quantity, using participant questionnaires, light exposure, and the feasibility of machine learning in activity‐pattern interpretation. Results: Women with recurrent implantation failure slept daily on average for 7 hours 35 minutes (± 57 min), 53 minutes less than the comparison group (P =.03), although quality of their objective sleep, and quantity of their subjective sleep, were not significantly different. Women with recurrent miscarriage slept less that the comparison women (36 minutes less/night) but more than women with recurrent implantation failure (17 minutes more/night). No difference in light exposure was found between recurrent miscarriage and the recurrent implantation failure and comparison groups. Conclusions: This study demonstrates an objective observation of sleep time reduction in women with subfertility, although it is not yet clear if this association is casual. Given our increased understanding of the internal body clock and circadian rhythm on fertility, our observation warrants further investigation. [ABSTRACT FROM AUTHOR]

This investigation surveyed the gynaecologic services and management available to women experiencing early pregnancy complications in the province of Ontario, Canada. The Chiefs of Gynaecology/Obstetrics of 61 Ontario hospitals were invited to complete a 55-item, online questionnaire using modified Dillman methodology. Forty-three hospital site respondents completed the survey (a response rate of 70.5%). It was reported that 18 (41.9%) hospitals had access to an early pregnancy assessment unit (EPAU), and 12 (66.7%) EPAUs had ≤2 days between the referral and the first appointment. Of the 25 (58.1%) hospital respondents without an EPAU, 14 (56.0%) reported previous consideration of creating an EPAU. At these hospitals, patients with early pregnancy complications have access to care through the ED (n = 22, 88.0%), obstetricians/gynaecologists (n = 22, 88.0%), person on-call (n = 16, 64.0%), family physicians (n = 11, 44.0%) or midwives (n = 9, 36.0%). This investigation found great heterogeneity in the care accessible to women experiencing early pregnancy complications in hospitals in Ontario, Canada. What is already known on this subject? Early pregnancy assessment units (EPAUs) are the standard for evaluating and caring for complications of early pregnancy. It has been well documented that EPAUs result in positive health service outcomes such as more cost-effective care, more timely management, and improved quality of care and patient satisfaction. What do the results of this study add? This investigation found that the province of Ontario, Canada has begun to adopt the EPAU model; however, a great heterogeneity exists in the care accessible to women experiencing early pregnancy complications throughout the province. Nonetheless, where EPAUs are available, they provide a structured referral system for women experiencing complications of early pregnancy that require gynaecologic assessment, such as ectopic pregnancy, providing close follow-up and predictable pathways of care for this patient population. What are the implications of these findings for clinical practice and/or further research? This study highlights the need for hospitals in the province of Ontario to improve their current service delivery models for women experiencing early pregnancy complications. Further research should be undertaken to determine whether the positive health service outcomes of EPAUs are also relevant in the Canadian healthcare system. [ABSTRACT FROM AUTHOR]

Objective: To assess the value of multiple serum biomarkers for the prediction of successful outcome of expectant management in women with tubal ectopic pregnancy (TEP).Study Design: Women with a conclusive ultrasound diagnosis of TEP had a blood test to measure β-human chorionic gonadotropin (β-hCG), progesterone, inhibin A, activin A and high sensitivity C-reactive protein (hsCRP) at the initial visit. Women presenting with pain, serum β-hCG ≥ 1500 IU, evidence of a live ectopic pregnancy or a significant haemoperitoneum were advised to have emergency surgery. Women eligible for expectant management were followed-up prospectively until serum β-hCG declined to non-pregnant level or surgical treatment was required.Results: A total of 93 women with a TEP were included in the final cohort. Emergency surgery was carried out in 42/93 (45 %) of women whilst 51/93 (55 %) were managed expectantly. Of the latter group, 42/51 (82 %) had successful expectant management and 9/51(18 %) required surgical procedure after a period of follow up. On multi-variable analysis, only higher values of serum β-hCG and progesterone at the initial visit were associated with a lower chance of successful expectant management of TEP. A one-unit increase in either variable on the log-scale was associated with an approximate 20-fold reduction in the odds of a successful outcome.Conclusion(s): Serum β-hCG and progesterone were significantly lower in women who had successful expectant management of TEP. Other biomarkers under consideration were not significantly different in women with successful and failed expectant management. [ABSTRACT FROM AUTHOR]

Objective: To evaluate longitudinal changes of angiogenic biomarkers in early- (EO-PD) versus late-onset (LO-PD) placental dysfunction. Methods: Serum PlGF and sFlt-1 measured at different intervals in EO-PD (n= 43), LO-PD (n= 31) and controls (n = 133). Results: sFlt-1/PlGF ratio was higher at 16 weeks (30.6 vs 17.5), 20 weeks (29.3 vs 8.9) and 30 weeks (16.6 vs 6.7) in EO-PD vs controls (all p< 0.05), but not in LO-PD. Longitudinal changes for all intervals had higher AUC than single measurements. Conclusion: Longitudinal biomarker change between 12 and 30 weeks could improve prediction of EO-PD compared to single measurements. [ABSTRACT FROM AUTHOR]

Background/aims: A new minimally invasive laparoscopic approach for ectopic pregnancy, the laparo-endoscopic single site surgery (LESS), has recently been introduced. The aim of this study is to compare the surgical outcome of this approach with conventional laparoscopy for ectopic pregnancy.Method: A review following the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement was performed. Electronic databases PubMed, MEDLINE, and Scopus were searched in December 2017 by searching the terms "single port laparoscopy" or "laparoendoscopic single site-surgery" or "single site laparoscopy" or "single-incision laparoscopic surgery" and "ectopic pregnancy." Studies comparing the 2 techniques and reporting surgical outcome were selected. Endpoints included comparison of length of operative time (OT), hemoglobin drop, length of hospitalization, number of patients requiring packed red blood cells (PRBC) transfusion, intra- and post-operative complication rates between patients undergoing conventional laparoscopy and those undergoing LESS.Results: A total of 56 studies were retrieved of which 5 studies including 460 patients met selection criteria. No differences were found between conventional laparoscopy and LESS with regards to length of OT time (even after stratification for presence of hemoperitoneum and/or adhesions), length of hospitalization, mean hemoglobin drop, number of patients requiring transfusions of PRBC, and intra- and post-operative complications.Conclusion: The management of ectopic pregnancies with LESS does not seem to be superior to conventional laparoscopy. [ABSTRACT FROM AUTHOR]

Introduction: Recently, an association between human papillomavirus infection and both spontaneous abortion and spontaneous preterm delivery was suggested. However, the reported human papillomavirus prevalence in pregnant women varies considerably and reliable conclusions are difficult. We aimed to investigate human papillomavirus infection in placental tissue of a Danish study cohort. Furthermore, we studied the cellular localization of human papillomavirus.Material and Methods: In this prospective case-control study, placental tissue was analyzed for human papillomavirus infection by nested PCR in the following four study groups: full-term delivery (n = 103), spontaneous preterm delivery (n = 69), elective abortion (n = 54), and spontaneous abortion (n = 44). Moreover, human papillomavirus cellular target was identified using in situ hybridization.Results: Human papillomavirus prevalence in placental tissue was 8.7% in full-term deliveries, 8.8% in spontaneous preterm deliveries, 10.9% in spontaneous abortions, and 20.4% in elective abortions. Twelve different human papillomavirus types were detected, and placental human papillomavirus infection was associated to a disease history of cervical cancer. Human papillomavirus DNA was identified in trophoblast cells, cells of the placental villi mesenchyme including Hofbauer cells, and in parts of the encasing endometrium.Conclusion: Placental human papillomavirus infections are not likely to constitute a risk factor for spontaneous preterm labor or spontaneous abortions in the Danish population, although an effect of human papillomavirus DNA in placental cells cannot be excluded. [ABSTRACT FROM AUTHOR]

Objectives: Women with rare intrauterine contraception (IUC) failures are advised to have their IUC removed because of the risk of poor obstetric outcomes with a retained IUC. Specifics regarding IUC removal in early pregnancy including techniques for removal, rates of success, and immediate pregnancy outcomes following removal are not well described, however. The objective of this study was to identify women with an IUC in early pregnancy examined at a tertiary care center with the primary objective of describing IUC removal attempts, IUC removal successes, and pregnancy outcomes at 20 weeks following IUC removal.Methods: Case series of women with concurrent IUC and early pregnancy who presented to a tertiary care ultrasound center by 12 weeks' gestation.Results: A total of 3116 women had an early pregnancy ultrasound during the study period. Nineteen (19/3116, 0.61%) women underwent ultrasounds that identified a pregnancy before 12 weeks and an IUC in the uterus. A copper IUC was identified in 11 women (11/19, 58%) on their first ultrasound, and a levonogestrel IUC was identified in 5 women (5/19, 26%). Seventeen (17/19, 88%) women attempted to remove their IUC; 11 of 69 (69%) were successfully removed on the first attempt. Fourteen (14/19; 74%) women with an IUC examined by 12 weeks' gestation had an ongoing pregnancy at 20 weeks compared with 1782 (1782/2678, 67%; P = 0.209) women without an IUC.Conclusions: Pregnancy with IUC is rare. Among the 19 women who were found to have an in situ IUC and early pregnancy, most had a successful IUC removal and had an ongoing pregnancy at 20 weeks' gestation. In our case series, IUC removal in the first trimester was a straightforward procedure and likely successful. [ABSTRACT FROM AUTHOR]

Objective: To study treatment modalities for cesarean scar pregnancies (CSPs), focusing on efficacy and complications in relation to study quality.Design: Systematic review.Setting: Not applicable.Patient(s): A total of 2,037 women with CSP.Intervention(s): Review of MEDLINE, EMBASE, and Cochrane Library to find studies including five or more women. Data were extracted on primary treatment modality/efficacy, complications, and future fertility. The level of evidence was categorized according to Oxford Centre for Evidence-based Medicine guidelines. Quality was assessed using The Cochrane Collaboration's Risk of Bias Tools for Randomized Controlled Trials and the modified Delphi techniques for case series. Meta-analysis was impossible owing to multifarious treatments.Main Outcome Measure(s): Successful first-line treatment. Complications were hysterectomy, laparotomy, bleeding >1,000 mL, or blood transfusion.Result(s): Fifty-two studies were included: four randomized, controlled trials and 48 case series. Fifteen of the 52 analyzed studies were scored as high quality. Treatment modalities were condensed to 14 different approaches. Combining study quality, level of evidence, efficacy, and safety, five approaches for treating CSP are recommended, depending on availability, severity of patient symptoms, and surgical skills: [1] resection through a transvaginal approach, [2] laparoscopy, [3] uterine artery embolization in combination with dilatation and curettage and hysteroscopy, [4] uterine artery embolization in combination with dilatation and curettage, and [5] hysteroscopy.Conclusion(s): This review recommends treatment options for CSP in clinical practice, based on efficacy and safety. The literature supports an interventional rather than medical approach. Present recommendations are primarily based on case series. Multicenter, well-designed studies are needed to draw definite conclusions on how to treat CSP. [ABSTRACT FROM AUTHOR]

Introduction Vaginal infection is a major causative factor of preterm delivery. The present study was performed to evaluate the effect of asymptomatic vaginal colonization with Candida albicans at early gestation on pregnancy outcome. Material and methods From 2005 to 2014, a total of 8447 women with singleton pregnancies between 10+0 and 16+0 gestational weeks were routinely subjected to an antenatal infection screen-and-treat program. Vaginal smears were Gram-stained and microscopically evaluated, and data were retrospectively analyzed. Women exposed to Candida received clotrimazole and were re-tested after 4-6 weeks. Treatment was repeated in case of recurrence. Women with normal or intermediate vaginal flora were considered as non-exposed. Bacterial vaginosis and trichomoniasis were assessed and treated as well. Descriptive data analysis, chi-squared testing and multiple regression analysis with adjustment for potential confounders were performed. Rates of asymptomatic vaginal infections, preterm delivery and low birthweight served as the main outcomes measures. Results A normal or intermediate flora was found in 6708 (79.4%) of the screened women; 1142 women (13.5%) showed asymptomatic C. albicans infection. Of this group, 185 women (2.2%) had a recurrence of Candida on vaginal smears. Compared with the non-exposed women with normal or intermediate flora, those with recurrent candidiasis had higher rates of preterm delivery (11.9% vs. 9.5%) and of low birthweight (10.8% vs. 8.0%), as confirmed in the multiple model ( p = 0.02). Conclusions Recurrent asymptomatic vaginal colonization with Candida in early pregnancy is associated with preterm delivery and low birthweight. Routine screening and consequent treatment for candidiasis could improve pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Objective To describe developments in reproductive long-term prognosis in women with a first ectopic pregnancy as compared with two control cohorts. Design Controlled cohort study. Setting Data were collected from four national Danish registries. Population All Danish women of reproductive age (15-49 years) through the period 1977-2009 and all reproductive outcomes in these women. Methods Data were collected from four national Danish registries. Three cohorts of women with a first recorded ectopic pregnancy during the periods 1980-84, 1985-89, and 1990-94, were compared with age-matched controls with a first miscarriage and a first induced abortion and followed for 15 years for all further pregnancy outcomes. Main outcome measures Pregnancy outcomes included deliveries, miscarriages, induced abortions and ectopic pregnancies. Results The birth rate for women with a first ectopic pregnancy increased significantly through the three cohorts from 85 to 122 deliveries/100 women during the follow-up period. The risk of miscarriages also increased over time, whereas the risk of further ectopic pregnancies remained unchanged at 22-24 events/100 women. Compared to women with a first miscarriage, the rate ratio for deliveries increased from 0.59 (95% CI 0.56-0.63) to 0.71 (95% CI 0.68-0.75) over the time covering the three cohorts. Conclusion The long-term delivery rate among women with a first ectopic pregnancy has improved significantly over time. [ABSTRACT FROM AUTHOR]

Objective Hypertensive disorders during pregnancy remain a major health burden. Normal pregnancy is associated with systemic cardiovascular adaptation. The augmentation index and pulse wave velocity measures may serve as surrogate markers of cardiovascular pathology, including pre-eclampsia. We evaluated these parameters during and after normotensive and pre-eclamptic pregnancies. Design Longitudinal cohort trial involving a case-control analysis of healthy women and women with pre-eclampsia. Setting University hospital. Population Fifty-three healthy pregnant women between 11+6 and 13+6 gestational weeks, as well as 21 patients with pre-eclampsia. Methods The augmentation index and pulse wave velocity were measured seven times during pregnancy and postpartum. Main outcome measures Changes in augmentation index and pulse wave velocity during and after healthy pregnancies were measured. The influence of early-onset and late-onset pre-eclampsia on these measurements both during and after pregnancy was evaluated. Results The normotensive pregnancies exhibited a significant decrease in the augmentation index from the first trimester to the end of the second trimester; however, the normotensive pregnancies showed an increase in the augmentation index during the third trimester as term approached. The patients with early-onset and late-onset pre-eclampsia displayed a significantly elevated augmentation index during pregnancy. The postpartum augmentation index and pulse wave velocity were significantly elevated in the early-onset pre-eclampsia group. Conclusion After pregnancy, early-onset and late-onset pre-eclamptic patients exhibit differences in vascular function. This result indicates the presence of a higher cardiovascular risk in patients after early-onset pre-eclampsia. [ABSTRACT FROM AUTHOR]

Objective. To investigate the feasibility of nationwide perinatal mortality audits in the Netherlands. Study design. Over a one-year period, data for all cases of perinatal mortality were collected. Six perinatal audit panels of professionals within perinatal care investigated and classified causes of death and identified the presence of substandard care factors (SSF). Results. Out of 22,189 newborns, 228 cases of perinatal mortality were audited. Placental pathology, congenital anomalies and preterm birth were the main causes of perinatal death. SSF by caregivers were identified in 72 cases (32 %). Almost 20% of the cases were not reported. Conclusions. In the Netherlands, perinatal audit is well supported by all groups of caregivers. It reveals usable facts and findings for the quality assessment of perinatal care. This audit showed that in 9% of the cases perinatal death was related to SSF and potentially avoidable. However, immediate reporting of cases of perinatal death apart from regular registration in the perinatal database proved to be inaccurate. Once a nationwide audit program is realized, in which data from the different caregivers will be collected in a single database instead of collection by linkage afterwards, this problem should be solved. Local audits will start from 2009. These audits will assess mortality cases within their respective areas and may initiate adjustments for perinatal care and optimize the quality of care and inter-professional collaboration. Yearly nationwide audits will focus on specific items (e.g. term or post-term deliveries) and may well offer an opportunity for the development or adjustment of national guidelines. [ABSTRACT FROM AUTHOR]

Little is known about the maternal cortisol awakening response (CAR) in the first pregnancy trimester. Similarly unknown is how the CAR in early gestation relates to other steroid hormones, such as estriol. Maternal estriol in blood and urine is used to monitor fetal well-being since it is produced by the fetoplacental unit from fetal precursors. Low levels have been associated with maternal-fetal complications. We were recently able to show that estriol is measurable in maternal saliva from 6 weeks' gestation onwards. However, its pattern following morning awakening and potential links with salivary cortisol in early gestation is relatively unknown. In this prospective study, we explored the cortisol and estriol responses to morning awakening in first-trimester pregnant women, the potential association of these endocrine variables with maternal stress and resilience factors, and their predictive value for the further pregnancy course. Fifty-one women with an uncomplicated, singleton pregnancy responded to questionnaires measuring chronic and pregnancy-specific stress, emotional support, and daily uplifts at 6 weeks' gestation. At 8 and 10 weeks, the women collected saliva samples immediately, 30, and 60 min after morning awakening. After 12 weeks, 40 women reported on the further pregnancy course, of whom 6 had developed complications. In response to morning awakening, cortisol levels increased significantly at 10 weeks (p =.04), while estriol levels decreased significantly at both 8 and 10 weeks (p <.001). A stronger cortisol increase was linked to a stronger estriol decrease at 8 (p =.03), but not at 10 weeks. Then, perceived emotional support at 6 weeks was negatively associated with cortisol baseline at 8 (p =.01) and positively with estriol baseline at 10 weeks (p =.03). Moreover, higher pregnancy-specific stress was related to a lower estriol baseline at 8 weeks (p =.047). Furthermore, compared to healthy women, those with complications at follow-up had already reported less emotional support (p =.03) and fewer daily uplifts (p =.03) at 6 weeks. These women also seemed to lack a significant estriol response to morning awakening at 8 weeks (p >.10). These findings advance our knowledge of cortisol and estriol secretion following morning awakening and encourage the investigation of E3 in addition to cortisol when researching prenatal stress and its consequences for maternal and fetal health. • Salivary cortisol increased from awakening to +30 min at 10, not 8 weeks' gestation. • Salivary estriol (E3) decreased upon awakening at both 8 and 10 weeks' gestation. • The cortisol increase was positively linked to the E3 decrease at 8, not 10 weeks. • Social support related to lower S1 cortisol at 8, higher S1 E3 levels at 10 weeks. • Higher prenatal distress at 6 weeks was linked to lower S1 E3 levels at 8 weeks. [ABSTRACT FROM AUTHOR]

Objectives: Women experiencing complications of early pregnancy frequently seek care in the emergency department (ED), because most have not yet established care with an obstetrical provider. The primary objective of this study was to explore the services available (ED management, ultrasound access, and follow-up care) for ED patients experiencing early pregnancy loss or threatened early pregnancy loss in Ontario hospitals., Methods: The emergency medicine chiefs of 71 Ontario hospital EDs with an annual census of more than 30,000 ED patient visits in 2017 were invited to complete a 30-item, online questionnaire using modified Dillman methodology., Results: Respondents from 63 EDs across Ontario completed the survey (response rate 88.7%). Of the EDs surveyed, 34 (54.0%) reported that they did not have access to early pregnancy clinic services for women who presented to the ED with early pregnancy complications that were safe to discharge home. At these hospitals, it was found that patients were followed up in 14 (41.2%) EDs for the same complications, including pregnancy of unknown location and threatened abortion. Respondents also stated that a radiologist-interpreted ultrasound was available to only 22 (34.9%) of hospital sites for 24 hours, 7 days per week for women with early pregnancy complications., Conclusions: The results of this study highlight the reliance of some hospitals on the ED to provide ongoing follow-up care to patients experiencing complications of early pregnancy. The lack of clinical resources and specialized personnel in Ontario hospital EDs makes supporting these women longitudinally unrealistic, exposing them to undue risk and complications.