Risk of retained placenta in women previously delivered by caesarean section: a population-based cohort study.

OBJECTIVE: To evaluate whether women with a caesarean section at their first delivery have an increased risk of retained placenta at their second delivery. DESIGN: Population-based cohort study. SETTING: Sweden. POPULATION: All women with their first and second singleton deliveries in Sweden during the years 1994-2006 (n = 258,608). Women with caesarean section or placental abruption in their second pregnancy were not included in the study population. METHODS: The risk of retained placenta at second delivery was estimated for women with a first delivery by caesarean section (n = 19,458), using women with a first vaginal delivery as reference (n = 239,150). Risks were calculated as odds ratios by unconditional logistic regression analysis with 95% confidence intervals (95%) after adjustments for maternal, delivery, and infant characteristics. MAIN OUTCOME MEASURES: Retained placenta with normal (≤1000 ml) and heavy (>1000 ml) bleeding. RESULTS: The overall rate of retained placenta was 2.07%. In women with a previous caesarean section and in women with previous vaginal delivery, the corresponding rates were 3.44% and 1.96%, respectively. Compared with women with a previous vaginal delivery, women with a previous caesarean section had an increased risk of retained placenta (adjusted OR 1.45; 95% CI 1.32-1.59), and the association was more pronounced for retained placenta with heavy bleeding (adjusted OR 1.61; 95% CI 1.44-1.79). CONCLUSIONS: Our report shows an increased risk for retained placenta in women previously delivered by caesarean section, a finding that should be considered in discussions of mode of delivery.

Limited impact of an intervention regarding emergency contraceptive pills in Sweden--repeated surveys among abortion applicants.

OBJECTIVE: To evaluate a community-based intervention consisting of an information campaign and advance provision of emergency contraceptive pills (ECP) to abortion applicants. METHODS: Submission of repeated waiting room questionnaires to abortion applicants in two cities in mid-Sweden; one intervention city (IC) and one comparison city (CC) in 2002 (IC = 92, CC = 95) and 2003 (IC = 244, CC = 204). RESULTS: The overall response rate was 90%. The percentage of women who had undergone an abortion within the previous year had decreased in the intervention group but not in the comparison group. Almost two-thirds (63%) of the targeted women had noticed the information campaign and one out of three (33%) who had visited a family planning clinic recalled being given information about ECP. There was a small decline in the use of combined oral contraceptives and intrauterine devices over time. After the intervention, women in the intervention city had better knowledge of ECP and had used it more than women in the comparison city did. CONCLUSIONS: More than half of the targeted women had noticed the information campaign and it may have had a limited impact. Further investigations are needed to determine whether advance supply of ECP to abortion applicants can reduce repeat abortions.

The effects of oral estriol on the endometrium in postmenopausal women.

OBJECTIVES: To study the long-term effects of oral estriol tablets on the endometrium of postmenopausal women by TVS and histology. METHOD: This was a cross sectional, parallel-group, multicenter trial of 241 postmenopausal women, out of whom 125 were treated with oral estriol and 116 were untreated controls. Endometrial histology using Pipelle biopsies and/or dilatation and curettage (D&C) was taken, endometrial thickness was assessed by use of transvaginal ultrasound (TVS), and the relation between endometrial thickness and histology was calculated. RESULTS: No statistically significant differences between the two groups were found in endometrial histology. There were found more polyps in the oral estriol group (14.0%) as compared with the control group (2.9%). The mean endometrial thickness in the oral estriol group was 3.0 mm compared with a mean value of 2.4 mm in the control group: P=0.01. CONCLUSIONS: No clinically relevant difference was found between the endometrium status (assessed by histology and TVS) of postmenopausal women on long-term oral estriol therapy and untreated controls. This trial supports the endometrial safety of maintenance treatment with oral estriol tablets. However, there are signs, not statistically significant, that may be associated with more endometrial polyps in postmenopausal women than if therapy is not given and that TVS is a useful instrument for the diagnosis.

Second trimester ultrasound screening performed by midwives; sensitivity for detection of fetal anomalies.

BACKGROUND: To assess the sensitivity for detection of fetal anomalies by a second trimester ultrasound screening program performed in a way representative of a majority of Swedish obstetrical departments. The examinations were performed at the ultrasound division of the Department of Obstetrics and Gynecology at the University Hospital of Uppsala, Sweden. METHOD: A prospective study covering a two-year period. Eight thousand two hundred and twenty-eight unselected, consecutive pregnant women (8345 fetuses) were examined. The ultrasound scans were performed at a gestational age of 15-22 weeks by specially trained midwives. All fetal anomalies suspected at the ultrasound screening were recorded. Follow-up of all scanned fetuses was done through neonatal reports, records from the pediatric department, a national malformation registry and autopsies. All live-born infants were followed one year after birth. Main outcome measures were sensitivity, specificity, and positive predictive value for detection of fetal anomalies and prevalence of fetal anomalies. RESULTS: In all 145 fetuses/infants with confirmed anomalies were identified (prevalence 1.7%). Thirty-two were detected by second trimester ultrasound screening (sensitivity 22.1%). Twenty false positive cases were identified, of which fifteen were ruled out on the same day the suspicion arose and five were transient findings. The specificity was 99.8% and the positive predictive value 61.5% CONCLUSIONS: When performing a second trimester ultrasound screening program, prenatal diagnosis of fetal anomalies will be part of the procedure whether this is a primary aim or not. It is therefore of great importance that the pregnant women receive adequate information and that the voluntariness of participation is stressed. In this study the sensitivity was low. Standardizing the scanning procedure (check-list for fetal anatomy) and improving the education of the operators are feasible ways to increase the sensitivity.

Perception of information, expectations and experiences among women and their partners attending a second-trimester routine ultrasound scan.

The aim of this study was to evaluate pre-scan counselling and the provision of information to parents-to-be, and their expectations before and experiences of a second trimester routine ultrasound scan. In the study, 303 pregnant women and their partners were asked to complete questionnaires before and after the scan. The main purposes of the examination were: dating, ascertaining fetal viability, and detection of multiple gestations. Although scanning for fetal malformations was not the purpose of the examination, 89% of the women and 84% of the men were concerned about this aspect. Even though it has been postulated that more women would not attend the examination if they knew it was for prenatal diagnostic purposes, the results of this study did not support this assumption. Only 57% of the women had received information at their antenatal care centers. A total of 88% of the women and 85% of the men said that they obtained sufficient information at the scan. Anxiety was low before the scan, both among women and men, with the exception of those women who had experienced problems at earlier scans. Positive feelings dominated during the scan and these feelings remained when experiences of the scan were reported by the parents-to-be after they had gone home. It is concluded that a routine second-trimester scan is a positive event for the majority of the participating women and men. In spite of this, we believe that certain measures should be taken to improve pre-scan counselling and the provision of adequate information.

Second trimester routine ultrasound and abnormal findings.

OBJECTIVE: To estimate the detection rate of abnormal findings, especially fetal anomalies, at second trimester ultrasound screening performed in a way representative of Swedish antenatal clinics. DESIGN: A prospective study carried out over two years in Uppsala county, Sweden, including 8,228 unselected pregnant women (8,345 fetuses). The ultrasound scans were performed by specially trained midwives. MAIN OUTCOME MEASURES: The number of abnormalities suspected by the midwives and the number of abnormalities confirmed by the obstetricians were registered, as was pregnancy outcome for these cases. RESULTS: Midwives reported suspected abnormalities at the screening procedure in 59 cases (0.7%), abnormalities were confirmed by obstetricians in 42 cases (0.5%, of which 0.36% were fetal malformations). Seventeen of these 42 pregnancies were terminated and 11 ended with miscarriages or intrauterine fetal deaths. Fourteen of the 42 pregnancies ended with a live born infant, of which two died postnatally. CONCLUSIONS: The described ultrasound screening procedure led to suspected abnormalities in 0.7% of the scanned cases and to confirmed abnormalities in 0.5% of the cases. The outcome for the confirmed abnormalities was poor, as 71% were either terminated or ended with miscarriage or perinatal death.

Pregnancy, ultrasound screening and smoking attitudes.

This questionnaire study was performed to evaluate screening as a tool to help reduce smoking among pregnant women and their partners. Three hundred women and their partners coming for ultrasound screening were asked to participate. Twenty-two percent of the women and 21% of the men were smoking regularly before pregnancy. Fifty-four percent of the women changed their smoking habits after knowledge of the pregnancy and before the scan. The corresponding figure for men was 19%. Before the scan 54% of the women and 49% of the men estimated their ability to stop smoking later in pregnancy as higher than 50%. The scan itself did not increase this figure. Among women with high consumption of cigarettes, the estimated ability to stop smoking was low.

Outcome for fetuses with abdominal wall defects detected by routine second trimester ultrasound.

The outcome for 70 fetuses with abdominal wall defects detected by routine second trimester ultrasound during the years 1983-90 was investigated. In 65 of the 70 cases the prenatal diagnoses were correct. Thirty-two women had their pregnancies terminated by legal abortions. Thirty-eight pregnancies continued. Six of these ended with spontaneous abortion or intrauterine fetal death. Thirty-two infants were born alive. Nearly all cases with associated malformations and all cases with chromosomal defects were in the omphalocele group. The neonatal survival for infants with gastroschisis and infants with omphalocele without associated malformations or chromosomal defects was high (96%).

Aldehyde-induced platelet aggregation.

Formaldehyde, acetaldehyde, malondialdehyde, glutaraldehyde and paraldehyde, when added in vitro to platelet-rich plasma, generate a similar distinct platelet aggregation response which is dose dependent when measured with a manual visual microscopic technique and by computerized image analysis, 'computerized platelet aggregation analysis'. Light transmission aggregometry did not measure this aggregation in a reliable manner. The aggregating reaction was specific to the aldehyde group and was not seen when the aldehyde was replaced by an alcohol, ketone, or acetate group in the case of acetaldehyde. The maximal aggregating effect of these aldehydes was directly proportional to the number of aldehyde groups per molecule. Aggregation was found to require the presence of plasma, but not von Willebrand's factor.

Multilevel care. A Veterans Administration initiative in health care cost control.

The Veterans Administration's (VA) Department of Medicine and Surgery, the largest of the civilian federal health care systems, is under continuous White House, congressional, and public pressure to provide greater accountability and increased cost-effectiveness for its $5 billion-plus annual budget. Responding to these pressures, the VA is evaluating in ten of its 172 medical centers a new system of resource allocation and financial management known as a multilevel care system. This is a major VA intiative with highly important implications for both the VA and the private health care sector.

Myelopoiesis in the infected burn.

A modified bone marrow clonal cell culture technique was used to study granulocyte production during burn injury and sepsis. When rats were inflicted with a 30 percent third-degree scald burn, marrow cellularity and colony-forming units in culture (CFU-C) per 10(5) marrow cells increased progressively to four times normal by 7 days after injury. Conversely, When animals were burned and the burn wound immediately seeded with 10(8) Pseudomonas organisms, CFU-C declined steadily until the day of death and reflected a progressive loss in marrow cellularity. Further studies were conducted replacing or mixing standard colony-stimulating serum with burn, burn-infected, or normal rat serum. The results indicated that colony-stimulating activity could be supplied by postburn serum, but not with normal or burn-infected rat serum. Additionally, serum from burned-infected animals significantly inhibited colony formation when added to the standard colony-stimulating serum. Marrow failure appears to be the major cause for granulocytopenia in burn infection and may partly be serum mediated.

The effects of dopamine on human platelet aggregation, in vitro.

An unexpected inhibition of human platelet aggregation by dopamine -- the precursor of epinephrine and norepinephrine -- is presented. Human platelet-rich plasma was incubated in an aggregometer for 120 seconds at 37 degrees C, with either dopamine or saline control. Adenosine diphosphate, epinephrine or collagen was added as the aggregating agent. Dopamine inhibits induction of platelet aggregation by all three agents and causes platelet disaggregation. At low doses (400 mug/ml or less), dopamine induces platelet aggregation and enhances ADP-induced aggregation. In addition, a concentration of dopamine of 40 mug/ml induces aggregation, enhances ADP-induced aggregation and inhibits epinephrine aggregation. Phentolamine is able to block dopamine enhancement of ADP aggregation, but propranolol and haloperidol fail to prevent dopamine inhibition of epinephrine aggregation. These observations are explained neither by the currently known intracellular actions of dopamine which involve competition with serotonin nor by a single mediator such as cyclic adenosine 3':5'-monophosphate. It appears that dopamine may exert its effects via the platelet membrane.

Unusual cytoplasmic inclusions in blast cells in acute leukemia.

A 36-year-old man manifested the clinical signs of acute leukemia. Blast cells in the blood and bone marrow contained many large cytoplasmic inclusions. Cytochemical and ultrastructural studies indicated that the leukemic cells were of lymphocytic origin. Three kinds of inclusions were identified on electron microscopy: one type of inclusion contained virus-like particles; another resembled those in cases with hairy cell leukemia; and the third appeared to be autophagic in nature. The presence of the second type of inclusion in the blast cells and the relative chronicity of the clinical course suggest that this patient's disease is of lymphocytic origin, similar to hairy cell leukemia.

Minimal heparin cofactor activity in disseminated intravascular coagulation and cirrhosis.

An assay technic for measuring heparin cofactor activity in which antithrombin activity can be assessed without plasma attenuation even in the presence of therapeutic levels of heparin is presented. Heparin-activated anti-thrombin activity was markedly depressed in plasmas of four patients with disseminated intravascular coagulation and in ten patients with cirrhosis. Residual activity in those plasmas appeared qualitatively normal, and no inhibitor (platelet factor IV activity) was observed. Plasmas from patients with disseminated intravascular coagulation and cirrhosis required more heparin to obtain in vitro clotting time prolongation equivalent to normal.

Granulocyte function and Pseudomonas burn wound infection.

Granulocyte function in burn injury has been evaluated with an in vitro animal assay. Bactericidal activity, using this technique, was markedly depressed only when granulocytes from scald burned rats were challenged with each of three strains of Pseudomonas aeruginosa in the presence of autologous postburn serum or heat-inactivated serum. Preincubation of postburn and normal serum at 37 degrees C for 1 h resulted in normal phagocytosis. These studies validate an investigation of plasma and/or granulocyte replacement therapy in the burned patient.