Massive perivillous fibrin deposition of the placenta and pregnancy outcome: A retrospective observational study.

INTRODUCTION: Massive perivillous fibrin deposition (MPVFD) in the placenta is associated with pregnancy complications and maternal disease. The aim of the current study was to contribute with increased knowledge regarding MPVFD by comparing maternal characteristics, obstetric and perinatal outcome and recurrence rate according to the degree of MPVFD. MATERIAL AND METHODS: This retrospective observational study included 141 cases of MPVFD collected between January 2003 to December 2018 in the Stockholm region, Sweden. The extent of fibrin deposition was assessed as low (20-32%), moderate (33-50%) or severe (>50%) according to macroscopic examination. RESULTS: The study covered 48 placentas with low MPVFD, 41 with moderate and 52 with severe MPVFD. Severe MPVFD was associated with more prematurity than moderate and low MPVFDs (56.3% vs 34.2% and 34.0% respectively, p = 0.05 and p = 0.04). In cases with severe MPVFD, 72.3% of the liveborn infants were growth-restricted compared to 34.2% in the moderate group (p = 0.001) and 52.2% in the low group (p = 0.06). The incidence of intrauterine fetal death was 31.3% in the severe MPVFD group, which was significantly higher than in the low MPVFD group (8.5%, p = 0.01) and twice as much as in cases with moderate MPVFD (15.8%, p = 0.07). 105 subsequent pregnancies after an index pregnancy with MPVFD were identified. The outcome was favourable with a liveborn rate of 91-100%. DISCUSSION: The extent of fibrin in the placenta plays a role in pregnancy outcome. Cases with severe MPVFD in the placenta was associated with more prematurity, fetal growth restriction and intrauterine fetal death.

Correction to: One Plus One Equals Two-will that do? A trial protocol for a Swedish multicentre randomised controlled trial to evaluate a clinical practice to reduce severe perineal trauma.

An amendment to this paper has been published and can be accessed via the original article.

One Plus One Equals Two-will that do? A trial protocol for a Swedish multicentre randomised controlled trial to evaluate a clinical practice to reduce severe perineal trauma {1}.

BACKGROUND: Severe perineal trauma sustained during childbirth is a serious complication since it can lead to both short- and long-term consequences for women. Some of the methods used to prevent perineal injuries have been evaluated in clinical trials, but there are still gaps in the evidence. A new clinical practice has been introduced, adopted by more than half of the maternity wards in Sweden with the aim of reducing severe perineal trauma. This procedure involves two midwives assisting the woman during the second stage of labour. METHODS/DESIGN: In this multicentre randomised controlled trial, 2946 women will be randomised to be assisted by one or two midwives during the second stage of labour. Women age 18-47, who plan for their first vaginal birth, with a singleton pregnancy in cephalic presentation, will be asked to participate when admitted to the maternity ward. Five maternity wards comprising 19,500 births/year in different parts of Sweden will participate in this study. The sample size is powered to demonstrate a 50% reduction (from 4.1-2.0%) in primary outcome, which is the prevalence of severe perineal trauma (3rd and 4th degree). Secondary outcomes will include maternal and neonatal outcomes, women's experiences, midwives' experiences of the intervention, incontinence, and pelvic floor symptoms. The primary analysis is intention to treat. Questionnaires will be sent to the women at 1 month and 1 year after the birth to assess women's experiences, pain, incontinence, pelvic floor symptoms, sexual function, and mental health. DISCUSSION: It is important for care during labour and birth to be evidence based. There is a strong desire among midwives to reduce the risk of severe perineal trauma. This may lead to new strategies and practices being implemented into practice without scientific evidence. The intervention might have negative side effects or unintended consequences. On the other hand, there is a possibility of the intervention improving care for women. TRIAL REGISTRATION {2A}: ClinicalTrials.gov NCT03770962 . Registered on 10 December 2018.

Traction force during vacuum extraction: a prospective observational study.

OBJECTIVE: To investigate the traction force employed during vacuum extractions. DESIGN: Observational cross-sectional study. SETTING: Obstetric Department, Karolinska University Hospital, Sweden, and the Swedish National Congress of Obstetrics and Gynaecology, 2013. POPULATION: Two hundred women with vacuum extraction at term and 130 obstetricians participating in a simulated setting. METHODS: In a normal clinical setting, we used a specially adapted device to measure and record the force used to undertake vacuum extraction. In a subsequent part of the study, the force employed for vacuum extraction by a group of obstetricians in a fictive setting was estimated and objectively measured. MAIN OUTCOME MEASURES: Applied force during vacuum extraction in relation to the estimated level of difficulty in the delivery; perinatal diagnoses of asphyxia or head trauma; estimated force compared with objectively measured force employed in the fictive setting. RESULTS: The median (minimum-maximum) peak forces for minimum, average and excessive vacuum extraction in the clinical setting were 176 N (5-360 N), 225 N (115-436 N), and 241 N (164-452 N), respectively. In 34% of cases a force in excess of 216 N was employed. There was no correlation between the umbilical arterial pH at delivery and the traction force employed during extraction. Four cases of mild hypoxic ischaemic encephalopathy were observed, three of which were associated with a delivery whereby excessive traction force was employed during the vacuum extraction. In the fictive setting, the actual exerted force was twice the quantitative estimation. The measured forces in the clinical setting were four times higher than that estimated in the fictive setting. CONCLUSIONS: Higher than expected levels of traction force were used for vacuum extraction delivery. As obstetricians tend to underestimate the force applied during vacuum extraction, objective measurement with instantaneous feedback may be valuable in raising awareness.

Contribution of endogenous endothelin-1 to basal vascular tone during normal pregnancy and preeclampsia.

OBJECTIVE: The aim of this study was to determine the physiologic role for endogenous endothelin in the regulation of vascular tone during normal pregnancy and preeclampsia. The vascular sensitivity to endothelin-1 during pregnancy was studied also. STUDY DESIGN: Forearm blood flow was measured by venous occlusion plethysmography during intra-arterial infusion of phosphoramidon, an endothelin-converting enzyme inhibitor, for 60 minutes, which was followed by co-infusion with endothelin-1 for 30 minutes. Three groups were studied: healthy nonpregnant women, normal pregnant women, and women with preeclampsia. RESULTS: There was a significant increase in forearm blood flow in the nonpregnant group after phosphoramidon infusion alone (73%+/-37%; P<.05). Phosphoramidon did not change forearm blood flow in pregnant subjects. Co-infusion with endothelin-1 significantly decreased forearm blood flow in both the nonpregnant and normal pregnant women (53%+/-7% and 40%+/-11%, respectively; P<.01). No response to endothelin-1 was found among women with preeclampsia. CONCLUSION: The vascular sensitivity to endothelin-1 is not altered during normal pregnancy in contrast to preeclamptic pregnancy, where no effect of endothelin-1 was seen. Reduced endothelin dependence during pregnancy might be one mechanism behind the fall in peripheral vascular resistance.

The role of endogenous endothelin in the regulation of uteroplacental and renal blood flow during pregnancy in conscious rats.

Advancing pregnancy is characterized by a ten-fold increase in uterine blood flow and a 50 per cent increase in renal blood flow. To evaluate the involvement of endogenous endothelin (ET) in these haemodynamic changes the effect of bosentan, an ETA/B receptor antagonist, on uteroplacental and renal blood flow was studied in awake pregnant Sprague-Dawley rats. Regional blood flows were measured using microsphere technique immediately prior to and 30 min after bosentan administration (20 mg/kg i.v.). Four groups of animals (term: 23 days) were included: bosentan was administered to ten rats at gestation day (GD) 19 and nine at GD 20-21. In addition, four rats at GD 19 and five animals at GD 20-21 received saline and served as control groups. Basal placental blood flow increased significantly from 19 days' gestation to 20-21 days. Basal myometrial blood flow did not change with gestational age. At gestation day 19 bosentan increased placental and myometrial blood flow significantly (80 per cent and 43 per cent, respectively, P<0.05). This effect was not observed at gestation days 20-21. Renal blood flow did not change in response to bosentan at GD 19 but decreased by 20 per cent at GD 20-21 (P<0.01). In conclusion, in the awake pregnant rat there is a significant endogenous ET dependent vasoconstrictor tone in the uteroplacental vessels that diminishes towards term. We speculate that this change in responsiveness to endogenous ET contribute to the increase in placental blood flow in late gestation.