Prior placental bed disorders and later dementia: a retrospective Swedish register-based cohort study.

OBJECTIVE: To investigate the association between a history of placental bed disorders and later dementia. DESIGN: Retrospective population-based cohort study. SETTING: Sweden. SAMPLE: All women giving birth in Sweden between 1973 and 1993 (1 128 709). METHODS: Women with and without placental bed disorders (hypertensive disorders of pregnancy including pre-eclampsia, fetal growth restriction, spontaneous preterm labour and birth, preterm premature rupture of membranes, abruptio placenta, late miscarriages) and other pregnancy complications were identified by means of the Swedish Medical Birth Register. International classification of disease was used. Data were linked to other National Registers. Participants were followed up until 2013. The Cox proportional hazards model was used to calculate hazard ratios for women with and without pregnancy complications and were adjusted for possible confounders. MAIN OUTCOME MEASURES: Diagnosis of vascular dementia and non-vascular dementia. RESULTS: Adjusted for cardiovascular disease and socio-demographic factors, an increased risk of vascular dementia was shown in women with previous pregnancy-induced hypertension (Hazard ratio [HR] 1.88, 95% CI 1.32-2.69), pre-eclampsia (HR 1.63, 95% CI 1.23-2.16), spontaneous preterm labour and birth (HR 1.65, 95% CI 1.12-2.42) or preterm premature rupture of membranes (HR 1.60, 95% CI 1.08-2.37). No statistically significant increased risk was seen for other pregnancy complications or non-vascular dementia even though many of the point estimates indicated increased risks. CONCLUSIONS: Women with placental bed disorders have a higher risk for vascular disease. Mechanisms behind the abnormal placentation remain elusive, although maternal constitutional factors, abnormal implantation as well as impaired angiogenesis have been suggested. TWEETABLE ABSTRACT: Placental bed syndromes associated with vascular dementia even after adjusting for cardiovascular disease.

Pregnancy-associated plasma protein-A is positively correlated with first-trimester skin microvascular reactivity.

OBJECTIVE: To investigate the relationship between levels of circulating maternal pregnancy-associated plasma protein-A (PAPP-A) and first-trimester maternal vascular function. METHODS: This was a cross-sectional study of 53 healthy, non-smoking, nulliparous pregnant women in Stockholm, Sweden. PAPP-A levels and vascular function were assessed during gestational weeks 11-14. Forearm skin microcirculation was investigated by laser Doppler perfusion imaging during iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP) to assess endothelium-dependent and -independent microvascular vasodilatation, respectively. Microvascular endothelial function index was calculated as peak ACh/peak SNP. Endothelium-dependent and -independent vasodilatation in the brachial artery was evaluated, respectively, by postischemic hyperemia-induced flow-mediated vasodilatation (FMD) and by response to sublingual intake of glyceryl trinitrate (GTN). RESULTS: PAPP-A was correlated with skin microvascular endothelial function index (ß = 1.008 (95% CI, 0.34-1.68), r2  = 0.17, P = 0.004). PAPP-A also correlated inversely with FMD (ß = -0.052 (95% CI, -0.094 to -0.011), r2  = 0.13, P = 0.014) but did not relate to forearm endothelial function index (i.e. FMD/GTN). The results were retained in multivariate analyses including known confounding factors. CONCLUSIONS: First-trimester endothelium-dependent skin microvascular reactivity was positively related to PAPP-A levels. If confirmed, these novel findings suggest that first-trimester skin microvascular reactivity could be a useful early pregnancy marker of placental function. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Longitudinal study of vascular structure and function during normal pregnancy.

OBJECTIVE: To examine alterations in maternal vascular structure and function during normal pregnancy. METHODS: We assessed brachial and central blood pressure, pulse-wave velocity and augmentation index (by pulse-wave analysis and applanation tonometry), common carotid artery structure (by ultrasonography) and endothelial function in the brachial artery (by postischemic hyperemia-induced flow-mediated vasodilatation by glyceryl trinitrate) and in the forearm skin microcirculation (by laser Doppler perfusion imaging during iontophoretic administration of acetylcholine and sodium nitroprusside) in 52 healthy nulliparous women at 14, 24 and 34 weeks' gestation, and at 9 months postpartum. RESULTS: During pregnancy, brachial and central systolic and diastolic blood pressures initially decreased but subsequently increased (all P < 0.05). Flow-mediated vasodilatation in the brachial artery increased during early pregnancy (P < 0.05), whereas non-specific vasodilatation by glyceryl trinitrate decreased (P < 0.01), indicating improved endothelial function. Thus, endothelial function index (forearm blood flow/glyceryl trinitrate) increased during pregnancy (0.30 ± 0.18 in the non-pregnant state at 9 months postpartum and 0.51 ± 0.19, 0.61 ± 0.39 and 0.49 ± 0.30 in the first, second and third trimesters, respectively) (P < 0.001). Endothelium-dependent skin microvascular reactivity to acetylcholine also increased (P < 0.01). Carotid-femoral pulse-wave velocity decreased during pregnancy (5.88 ± 0.91 m/s in the non-pregnant state and 5.55 ± 0.67, 5.12 ± 0.66 and 5.62 ± 0.74 m/s in the first, second and third trimesters, respectively) (P < 0.001). CONCLUSION: During normal pregnancy, the blood volume expansion necessary for sufficient fetal growth is accommodated by early and marked changes in the matvascular system. This seems to be dependent on normal adaptive endothelial and vascular function. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Fetal growth is associated with first-trimester maternal vascular function.

OBJECTIVE: To investigate the relationship between maternal endothelial function in the first trimester, assessed in both the brachial artery and the forearm skin microcirculation, and fetal growth. METHODS: Vascular function was assessed in 56 pregnant women during gestational weeks 11-14. Vascular reactivity in the brachial artery was evaluated by postischemic hyperemia-induced flow-mediated vasodilatation (FMD) and by vasodilatation following administration of sublingual glyceryl trinitrate (GTN). Forearm skin microcirculation was investigated by laser Doppler perfusion imaging during iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP) to assess endothelium-dependent and -independent microvascular vasodilatation, respectively. Fetal growth was measured at study inclusion and birth-weight centile was calculated after delivery. RESULTS: FMD and GTN-induced vasodilatation were both associated with birth-weight centile. On multivariate analysis (adjusted for brachial artery diameter at rest, blood pressure, maternal age and heart rate), for FMD ß = 1.7 (95% CI, 0.06-3.34), r2 = 0.26 and P = 0.042, and for GTN-induced vasodilatation ß = 2.6 (95% CI, 0.44-4.68), r2 = 0.15 and P = 0.02. Endothelium-dependent and -independent microvascular reactivity were also associated with birth-weight centile: for ACh ß = 7.82 (95% CI, 1.81-13.83), r2 = 0.12 and P = 0.029, and for SNP ß = 6.27 (95% CI, 1.20-11.34), r2 = 0.11 and P = 0.016. CONCLUSION: First-trimester maternal vascular dilatation capacity (rather than endothelial function alone) is associated with fetal growth. These findings were consistent in both the brachial artery and the forearm skin microcirculation. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Psychiatric illness in women requesting caesarean section.

OBJECTIVE: To compare psychiatric in- and outpatient care during the 5 years before first delivery in primiparae delivered by caesarean section on maternal request with all other primiparae women who had given birth during the same time period. DESIGN: Prospective, population-based register study. SETTING: Sweden. SAMPLE: Women giving birth for the first time between 2002 and 2004 (n = 64 834). METHODS: Women giving birth by caesarean section on maternal request (n = 1009) were compared with all other women giving birth (n = 63 825). The exposure of interest was any psychiatric diagnosis according to the International Statistical Classification of Diseases and Related Health Problems (ninth revision, ICD-9, 290-319; tenth revision, ICD-10, F00-F99) in The Swedish national patient register during the 5 years before first delivery. MAIN OUTCOME MEASURES: Psychiatric diagnoses and delivery data. RESULTS: The burden of psychiatric illnesses was significantly higher in women giving birth by caesarean section on maternal request (10 versus 3.5%, P < 0.001). The most common diagnoses were 'Neurotic disorders, stress-related disorders and somatoform disorders' (5.9%, aOR 3.1, 95% CI 1.1-2.9), and 'Mood disorders' (3.4%, aOR 2.4, 95% CI 1.7-3.6). The adjusted odds ratio for caesarean section on maternal request was 2.5 (95% CI 2.0-3.2) for any psychiatric disorder. Women giving birth by caesarean section on maternal request were older, used tobacco more often, had a lower educational level, higher body mass index, were more often married, unemployed, and their parents were more often born outside of Scandinavia (P < 0.05). CONCLUSIONS: Women giving birth by caesarean section on maternal request more often have a severe psychiatric disease burden. This finding points to the need for psychological support for these women as well as the need to screen and treat psychiatric illness in pregnant women.

Caesarean section and risk for endometriosis: a prospective cohort study of Swedish registries.

OBJECTIVE: To investigate the association between caesarean section and later endometriosis. DESIGN: A prospective cohort study. SETTING: The Swedish Patient Register (PAR) and the Swedish Medical Birth Registry (MBR). SAMPLE: Women who were delivered in Sweden between 1986 and 2004. METHODS: Women with the diagnosis of endometriosis, defined as codes 617 (International Classification of Diseases, ninth revision, ICD-9) or N80 (ICD-10), were retrieved from the PAR. Obstetric outcome was assessed through linkage with the MBR. Out of 709,090 women, 3110 were treated as inpatients with a first diagnosis of endometriosis after their first delivery. Women with a diagnosis of endometriosis before their first delivery were excluded. Cox analyses were performed to obtain hazard ratios for endometriosis and adjusted for maternal age at first delivery, body mass index, maternal smoking, and years of involuntary childlessness at study entry. Kaplan-Meier estimates were performed to calculate the risk according to time elapsed. MAIN OUTCOME: In-hospital diagnosis of endometriosis. RESULTS: The Cox analyses yielded a hazard ratio of 1.8 (95% CI 1.7-1.9) for endometriosis in women who had had a previous caesarean section compared with women with vaginal deliveries only. The risk of endometriosis increased over time: one additional case of endometriosis was found for every 325 women undergoing caesarean section within 10 years. No increase in risk could be seen after two caesarean deliveries. The risk of caesarean scar endometrioma was 0.1%. CONCLUSION: In addition to the recognised risk of scar endometrioma, we found an association between caesarean section and general pelvic endometriosis. Further studies are needed to confirm our findings.

Starting time for induction of labor and the risk for night-time delivery.

OBJECTIVE: To analyze if starting time for labor induction affected the risk of night-time delivery, and to evaluate to what extent the risk was influenced by Bishop score at start of induction, mode of induction, and parity. METHOD: A retrospective cohort study of women who delivered at Danderyd Hospital, Stockholm, Sweden, 2002-2006, comprising 1940 women induced by Dinoprostone (PGE(2)) or transcervical balloon catheter (BARD). Risks for night-time delivery were calculated as absolute risk and Odds Ratios by unconditional logistic regression using induction of labor in the morning as reference. RESULTS: For nulliparae with Bishop score 0-3 induced by BARD, odds ratios for night-time delivery were 0.42 (95% C.I. 0.19-0.93) and 0.09 (95% C.I. 0.02-0.47) when inductions started in the afternoon and evening, respectively, compared to inductions starting in the morning For multiparae, however, the risk of night-time delivery was highest if induction started in the evening. Compared to inductions started in the morning, odds ratios for night-time delivery were 3.53 (95% C.I. 2.57-4.83) and 8.49 (95% C.I. 4.45-16.19) for induction starting in the afternoon and evening, respectively. CONCLUSION: Starting time of labor induction affects the risk of giving birth at night. For nulliparae induced by BARD, starting the induction in the evening instead of during the day may reduce the number of night-time deliveries substantially. For multiparae, however, our data suggest that induction of labor should take place in the morning.

Large fetal size in early pregnancy associated with macrosomia.

OBJECTIVE: To assess if fetal size at the time of ultrasound dating examination is associated with the risk of macrosomia and complications associated with macrosomia. METHODS: This was a retrospective cohort study of 19 377 singleton pregnancies dated in gestational weeks 16-20 during the period 1998-2004 at Danderyd Hospital, Stockholm, Sweden. Obstetric outcome was assessed through linkage to the Swedish Medical Birth Register. RESULTS: When fetuses were > or = 7 days larger than expected at dating, compared with the expected size according to last menstrual period, there was a 59% increase in the risk of birth weight > or = 4500 g and a 145% increase in the risk of birth weight > or = 5000 g (odds ratio (OR), 1.59; 95% CI, 1.12-2.24 and OR, 2.45; 95% CI, 1.22-4.90, respectively). For a birth weight of > or = 4000 g the risk estimate was 1.19 (95% CI, 0.96-1.47). CONCLUSION: Fetuses that are larger than expected in the second trimester have an increased risk of macrosomia. This emphasizes that fetal size in early pregnancy is not only a function of gestational duration, but also of fetal growth. However, only a limited proportion of all infants born macrosomic can be identified as such at the time of ultrasound dating.

Expected day of delivery from ultrasound dating versus last menstrual period--obstetric outcome when dates mismatch.

OBJECTIVE: To analyse the association between fetal size at time of dating ultrasound and risk for preterm delivery and small-for-gestational-age (SGA) birth and to evaluate if timing of ultrasound, that is before 14 weeks of gestation or after 16 weeks affects this association. DESIGN: Retrospective cohort study. SETTING: Ultrasound departments of Ultragyn, Stockholm, Sweden. POPULATION: A total of 28,776 singleton pregnancies dated between 1998 and 2004. METHODS: Obstetric outcome was assessed through linkage of the cohort to the Swedish Medical Birth Register. MAIN OUTCOME MEASURES: Risks of preterm delivery, low birthweight for gestational age, pre-eclampsia, asphyxia, respiratory distress, instrumental delivery, caesarean section, and postterm birth were calculated for the groups dated early and late. RESULTS: When the expected date of delivery was postponed after ultrasound dating by 7 days or more, there was an increased risk for preterm delivery and pre-eclampsia in the late dating group (OR 1.49, 95% CI 1.27-1.73 and OR 1.27, 95% CI 1.02-1.60, respectively) but not in the early dating group. In both dating groups, there was an increased risk for SGA birth (OR 1.77, 95% CI 1.13-2.78 and OR 2.09, 95% CI 1.59-2.73, respectively) There was no increased risk for any of the other diagnoses. CONCLUSION: Our study gives further support to the notion that intrauterine growth restriction may be present as early as the first trimester. Accordingly, our study also suggests that surveillance of pregnancies with postponed estimated date of delivery may provide means for increased detection of fetal growth restriction.

Expectation and experiences of childbirth in primiparae with caesarean section.

OBJECTIVE: The aim of this study was to examine the expectations and experiences in women undergoing a caesarean section on maternal request and compare these with women undergoing caesarean section with breech presentation as the indication and women who intended to have vaginal delivery acting as a control group. A second aim was to study whether assisted delivery and emergency caesarean section in the control group affected the birth experience. DESIGN: A prospective group-comparison cohort study. SETTING: Danderyd Hospital, Stockholm, Sweden. SAMPLE: First-time mothers (n= 496) were recruited to the study in week 37-39 of gestation and follow up was carried out 3 months after delivery. Comparisons were made between 'caesarean section on maternal request', 'caesarean section due to breech presentation' and 'controls planning a vaginal delivery'. METHODS: The instrument used was the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ). MAIN OUTCOME MEASURES: Expectations prior to delivery and experiences at 3 months after birth. RESULTS: Mothers requesting a caesarean section had more negative expectations of a vaginal delivery (P < 0.001) and 43.4% in this group showed a clinically significant fear of delivery. Mothers in the two groups expecting a vaginal delivery, but having an emergency caesarean section or an assisted vaginal delivery had more negative experiences of childbirth (P < 0.001). CONCLUSIONS: Women requesting caesarean section did not always suffer from clinically significant fear of childbirth. The finding that women subjected to complicated deliveries had a negative birth experience emphasises the importance of postnatal support.

Discordant twin growth in utero and differences in blood pressure and endothelial function at 8 years of age.

OBJECTIVE: Low birth weight is associated with increased prevalence of hypertension and cardiovascular disease in adults. The aim of this study was to evaluate genetic and intrauterine environmental contributions to blood pressure (BP) and vascular functions in twins with discordant growth in utero. SUBJECTS: We studied 31 twin pairs (21 monozygous and nine dizygous), mean age 8 years) with large within-pair differences in birth weight. Among the monozygous pairs, nine had suffered from twin-to-twin-transfusion syndrome (TTTS). METHODS: Apart from BP, we determined diameters and elasticity of the carotid artery and abdominal aorta with ultrasonography, and endothelial function in skin vessels with a laser Doppler technique, before and after transdermal delivery of acetylcholine and nitroglycerin. RESULTS: Eight of 62 twin subjects had a systolic BP above the 90th percentile in a North-American reference population. Among these, seven/eight were monozygous with a history of poor fetal growth and/or TTTS. In monozygous twin pairs without TTTS, systolic BP and pulse pressure were higher and vascular endothelial function was impaired in the lower birth weight twin. In the TTTS group, the lighter twin had a narrower carotid artery but there was no within-pair difference in arterial elasticity. Pre-eclampsia during the index pregnancy enhanced within-pair differences in BP but abolished within-pair differences in endothelial function. CONCLUSIONS: Severe fetal growth retardation contributes to higher BP, arterial narrowing and endothelial dysfunction in childhood. Pre-eclampsia may act both as an effect modifier and confounder of these associations.

Transvaginal ultrasonographic findings in the uterus and the endometrium: low prevalence of leiomyoma in a random sample of women age 25-40 years.

BACKGROUND: In articles and textbooks the prevalence of uterine leiomyomas is said to be 20-25% in women over the age of 30. The aim of this study was to investigate the rate of uterine leiomyoma, the thickness and the texture of the endometrium, and the size of the uterus in a random sample of asymptomatic women 25-40 years old. METHODS: A random sample of women 25-40 years old was offered a transvaginal ultrasonographic examination and 335 (72%) accepted the invitation. RESULTS: In 18 women uterine leiomyomas were detected, i.e. 5.4% (95% CI 3.0-7.8%). The prevalence of leiomyomas increased with age, being 3.3% (95% CI 0.7-6.0%) in the 25-32 years age group and 7.8% (95% CI 3.6-12.0%) in the 33-40 age group. The size of the uterus correlated to parity, age and height. In women on combined oral contraceptives the size of the uterus was smaller than in women with natural cycles. The size of the uterus did not correlate to body mass index, cycle day or smoking habits. The endometrium increased in thickness and had in most cases a triple line appearance during the proliferative phase until day 15, whereafter it was unchanged in thickness throughout the secretory phase and hyperechogenic in appearance. CONCLUSIONS: This study confirms earlier studies on the endometrium based on selected populations. The size of the uterus increased with parity, age and height, and was smaller in combined oral contraceptive users. The prevalence figures for uterine leiomyomas in textbooks are not confirmed.

Disaccordance between estimation of endometrial thickness as measured by transvaginal ultrasound compared with hysteroscopy and directed biopsy in breast cancer patients treated with tamoxifen.

OBJECTIVE: To estimate endometrial thickness by transvaginal ultrasound technique (TVU) in patients treated with tamoxifen; and to compare the results with hysteroscopy and directed biopsy, and to relate the findings to curettage material. METHODS: Fifty-four women, over 50 years of age at the time of their primary breast cancer operation and scheduled for adjuvant treatment of tamoxifen, were investigated. If the endometrium measured 8 mm or more (35 patients) hysteroscopy and directed biopsy was performed. RESULTS: In the 35 patients, hysteroscopy and curretage revealed polyps in 18 cases (51.4%), proliferation in 1 case (2.9%) and atrophy in 16 cases (45.7%). In 54.3% (19 cases) of the patients the histopathological finding was a polyp or benign proliferation of the endometrium in agreement with the thickened endometrium seen with TVU. In the remaining 45.7% (16 cases) of the patients a thickened endometrium by transvaginal ultrasound was false positive as the hysteroscopic and subsequent histopathological diagnosis only showed atrofia of the uterine endometrium. CONCLUSIONS: In almost half of the patients the TVU gave a misleading picture concerning the condition of the endometrium. Changes in the myometrium and related connective tissue could be misinterpreted by the ultrasound technique as changes in the endometrium. These results may confirm the theory that stimulation and changes by antiestrogenic treatment of the uterine tissue is not only restricted to the endometrium. In patients with thickened endometrium measured by TVU, a dilatation and curettage is not sufficient, as TVU has not the ability to differentiate between endometrial polyps and myometrial changes. A hysteroscopy and directed biopsy could therefore be performed.

[Gynecological ultrasound is of uncertain value in screening]. / Gynekologiskt ultraljud av oklart värde vid screening.

In the past ten years, gynecological ultrasonography has proliferated rapidly, and is by some gynecologists considered an integral part of the gynecological exam. Abnormalities are detected in a asymptomatic women at a high rate, resulting in a number of surgical interventions due to suspected malignancy. Present evidence is insufficient to determine the medical and economical value, if any, of surgical removal. Such intervention may in fact be as detrimental as leaving an abnormality in place. Gynecological ultrasonography should therefore be performed on strict medical indications. Proper training of operators is also vital.

Transvaginal sonographic ovarian findings in a random sample of women 25-40 years old.

OBJECTIVE: To investigate the occurrence rate of adnexal lesions in premenopausal women. METHODS: A random sample of women 25-40 years old was invited to undergo a transvaginal ultrasound examination, and 335 women were examined. The criteria used to define an adnexal lesion were either a cystic lesion with its largest diameter of at least 25 mm within the pelvic region, or the appearance of solid parts in any lesion regardless of size. RESULTS: Adnexal lesions were found in 26/335 cases, (7.8%) (95% confidence interval (CI), +/- 2.9%). The occurrence rate of ovarian cysts was 22/335 (6.6%) (95% CI, +/- 2.7%). There were no differences between the women with or without ovarian cysts related to age, smoking habits, parity or body mass index. At follow-up 3 months later, 18 of the 22 (82%) cysts had disappeared (95% CI, +/- 16%). Women using progesterone contraception (either oral contraception or an intrauterine device with levonorgestrel) had a significantly higher relative risk of 2.7 (95% CI, 1.1-6.9) of functional cysts as compared to women with natural cycles. Polycystic ovaries were found in 10.2% (95% CI, +/- 4.2%) of the women not using any hormonal contraception. The mean volumes of the polycystic ovaries were significantly larger compared to those in natural cycles. CONCLUSION: Adnexal lesions are common in asymptomatic women in the age group 25-40 years, but four out of five ovarian cysts disappeared spontaneously after 3 months. The ultrasound appearance of the cyst, the woman's family history and her own feelings must be considered if a persisting cyst is to be surgically removed or followed by repeated transvaginal ultrasound.

Histopathologic findings in thickened endometria, as measured by ultrasound in asymptomatic, postmenopausal breast cancer patients on various adjuvant treatment including tamoxifen.

Pallents with breast cancer exhibit an increased risk of developing cancer from other organs, a risk that might increase due to tamoxifen treatment. This drug has been found to cause activation of oestrogen receptors, leading to oestrogenic effects on the postmenopausal endometrium. We report follow-up of 94 patients with breast cancer without initial symptoms aged more than 50 years at the time of operation. They were followed-up with vaginal ultrasound at regular intervals and endometrial sampling was performed according to treatment after surgery: tamoxifen, tamoxifen in combination with other regimes and without tamoxifen treatment. A large proportion were investigated prior to treatment. We identified endometrial carcinoma, metastasis of breast carcinoma and histopathological changes in 17/67 (25%) of the patients treated with tamoxifen compared to 1/32 in those not treated with tamoxifen.

Amniocentesis before the 15th gestational week in single and twin gestations-complications and quality of genetic analysis.

BACKGROUND: Early amniocentesis has been claimed to confer a higher risk of fetal loss than standard amniocentesis after the 15th gestational week. Our experience of early amniocentesis in single and twin gestations from 1990 - 1995 is presented with 99.3% follow-up. METHODS: Amniocentesis was performed between 11 gestational weeks + 5 days and 14 gestational weeks + 6 days. RESULTS: In 1646 pregnancies 1678 amniocenteses were performed. Thirty-two reamniocenteses were done, 17 due to amniocyte culture failure and 15 due to failure to obtain sufficient amount of amniotic fluid on the first occasion. After puncture 1.49% (25/1678) suffered a spontaneous abortion. Twenty twin pregnancies were included. One spontaneous abortion was noted in this group, as well as three cases where one fetus was normal and the other had a severe defect. Selective abortions were performed without complications. CONCLUSIONS: The difference of postprocedure fetal loss in our population between early and standard amniocentesis is 0.8%. A comparison of postprocedure losses is not appropriate when amniocenteses are performed at a different gestational age, as spontaneous loss decreases with increased gestational age. Our results compare well with the only randomized study between early and standard amniocentesis where the fetal loss after early amniocentesis is similar to that in standard amniocentesis.

Changes in ultrasound appearance of the internal female genital organs during treatment for eating disorders.

OBJECTIVE: To confirm that changes of the internal female genital organs in patients with eating disorders can be detected with ultrasound and that successive normalization can be followed during treatment. STUDY DESIGN: Thirty-five women with the diagnoses of eating disorders were examined with ultrasound while undergoing psychiatric treatment. The endometrial thickness and ovarian volume were measured. The sonographic picture of the ovaries was classified in four classes. RESULTS: Bulimics had changes of their ovaries in spite being of normal weight. After psychiatric treatment and a normal diet, the ovaries and the bleeding pattern normalized without a change in body weight. In anorectics, undetectable ovaries or ovaries without follicles were associated with low body mass index (BMI), but multifollicular ovaries or presence of a dominant follicle and ovarian volume had no clear relation to BMI. The endometrial thickness correlated with BMI. CONCLUSION: Ovarian morphology appeared more important than ovarian size. Changes of the ovaries appeared more related to eating patterns than to BMI. Eating disorders should be considered in women with bleeding disorders. Ultrasound examination can contribute to the differential diagnosis.

Endometrial thickness and ovarian cysts as measured by ultrasound in asymptomatic postmenopausal breast cancer patients on various adjuvant treatments including tamoxifen.

Endometrial thickness as measured by ultrasound during tamoxifen treatment has previously been reported. However, there has not been any study investigating endometrial thickness before treatment and following it at regular intervals during treatment. 90 patients with breast cancer without any gynecological symptoms were followed (aged more than 50 years at the operation of their breast cancer). They were investigated by vaginal ultrasound and a common clinical investigation at our out-care patient department. Adjuvant breast cancer therapy consisted of tamoxifen, tamoxifen after radiotherapy and/or in a few cases cytostatics, cytostatics with or without the addition of radiotherapy, radiotherapy or no further therapy. Patients with receptor positive tumours were given tamoxifen. Their endometrium was already thicker before the start of adjuvant treatment as measured by ultrasound. After 3 months and 12 months we found the endometrium to be significantly thicker in those treated with tamoxifen compared to other treatment groups. After 12 months of tamoxifen treatment 22/32 women had an endometrial thickness of 5 mm or more. The frequency of ovarian cysts also seemed to be affected by therapy. In patients treated with tamoxifen alone or in combination, the frequency of cysts was 5/35 before treatment, 6/37 after 3 months, and 0/32 after one year. The corresponding frequencies for those not treated with tamoxifen were 2/20, 3/11 and 3/23 respectively.