Associations of ultrasound estimated early mid pregnancy visceral and subcutaneous fat depths and early pregnancy BMI with adverse neonatal outcomes.

This study investigated whether maternal central adiposity and body mass index (BMI) were associated with neonatal hypoglycemia and adverse neonatal outcomes. A cohort study was performed at Uppsala University Hospital, Sweden, between 2015 and 2018. Visceral and subcutaneous fat depths were measured by ultrasound at the early second-trimester anomaly scan in 2771 women giving birth to singleton infants. Body mass index was assessed in early pregnancy. Logistic regression models were performed. Adjustments were made for age, BMI (not in model with BMI as exposure), smoking, maternal country of birth, and parity. Outcomes were neonatal hypoglycemia (blood glucose concentration < 2.6 mmol/l), a composite of adverse neonatal outcomes (Apgar < 7 at 5 min of age, or umbilical artery pH ≤ 7.0, or admission to neonatal intensive care unit), and the components of the composite outcome. Visceral and subcutaneous fat depths measured by ultrasound in early mid pregnancy were not associated with any of the outcomes in adjusted analyses. For every unit increase in BMI, the likelihood of neonatal hypoglycemia increased by 5% (aOR 1.05, 95% CI 1.01-1.10), the composite outcome by 5% (aOR 1.05, 95% CI 1.01-1.08), and admission to neonatal intensive care unit by 6% (aOR 1.06, 95% CI 1.02-1.10).

Association of maternal central adiposity measured by ultrasound in early mid pregnancy with infant birth size.

We sought to investigate whether early mid pregnancy visceral and subcutaneous fat depths measured by ultrasound were associated with infant birth size, independent of early pregnancy BMI. A cohort study was performed at Uppsala University Hospital, Sweden, between 2015-2018. Visceral and subcutaneous fat depths were measured at the early second-trimester anomaly scan in 2498 women, giving birth to singleton, term infants. Primary outcomes were birthweight and LGA (birthweight standard deviation score > 90th percentile in the cohort). Linear and logistic regression models were used, adjusted for BMI, age, smoking, parity, maternal country of birth, gestational age and infant sex. A 5-mm increase in visceral fat depth was associated with an increase in birthweight of 8.3 g [95% confidence interval (CI) 2.5 - 14.1 g], after adjustments, and a 6% increase in the adjusted odds of having an infant born LGA (OR 1.06, CI 1.02-1.11). There was no association between subcutaneous fat depth and birthweight or LGA after covariate adjustments. Hence, visceral fat depth measured by ultrasound in early mid pregnancy was associated with excessive fetal growth, independent of early pregnancy BMI, and may be useful in models for predicting LGA infants.

Placental location, postpartum hemorrhage and retained placenta in women with a previous cesarean section delivery: a prospective cohort study.

OBJECTIVE: Women previously giving birth with cesarean section have an increased risk of postpartum hemorrhage (PPH) and retained placenta. The objective of this study was to determine if anterior placental location increased the risk of PPH and retained placenta in such women. MATERIALS AND METHODS: We performed a prospective cohort study on 400 women with cesarean section delivery in a previous pregnancy. Ultrasound examinations were performed at gestational week 28-30, and placental location, myometrial thickness, and three-dimensional vascularization index (VI) were recorded. Data on maternal age, parity, BMI, smoking, gestational week at delivery, induction, delivery mode, oxytocin, preeclampsia, PPH, retained placenta, and birth weight were obtained for all women. Outcome measures were PPH (≥1,000 mL) and retained placenta. RESULTS: The overall incidence of PPH was 11.0% and of retained placenta 3.5%. Twenty-three women (11.8%) with anterior placenta had PPH compared to 12 (6.9%) with posterior or fundal locations. The odds ratio was 1.94, but it did not reach statistical significance. There was no significant risk increase for retained placenta in women with anterior placentae. Seven of eight women with placenta previa had PPH, and four had retained placenta. CONCLUSIONS: The overall risk of PPH and retained placenta was high for women with previous cesarean section. Anterior location of the placenta in such women tended to impose an increased risk for PPH but no risk increase of retained placenta. Placenta previa in women with previous cesarean section is associated with a high risk for PPH and retained placenta.

MuSK: a new target for lethal fetal akinesia deformation sequence (FADS).

BACKGROUND: Fetal akinesia deformation sequence syndrome (FADS, OMIM 208150) is characterised by decreased fetal movement (fetal akinesia) as well as intrauterine growth restriction, arthrogryposis, and developmental anomalies (eg, cystic hygroma, pulmonary hypoplasia, cleft palate, and cryptorchidism). Mutations in components of the acetylcholine receptor (AChR) pathway have previously been associated with FADS. METHODS AND RESULTS: We report on a family with recurrent fetal loss, where the parents had five affected fetuses/children with FADS and one healthy child. The fetuses displayed no fetal movements from the gestational age of 17 weeks, extended knee joints, flexed hips and elbows, and clenched hands. Whole exome sequencing of one affected fetus and the parents was performed. A novel homozygous frameshift mutation was identified in muscle, skeletal receptor tyrosine kinase (MuSK), c.40dupA, which segregated with FADS in the family. Haplotype analysis revealed a conserved haplotype block suggesting a founder mutation. MuSK (muscle-specific tyrosine kinase receptor), a component of the AChR pathway, is a main regulator of neuromuscular junction formation and maintenance. Missense mutations in MuSK have previously been reported to cause congenital myasthenic syndrome (CMS) associated with AChR deficiency. CONCLUSIONS: To our knowledge, this is the first report showing that a mutation in MuSK is associated with FADS. The results support previous findings that CMS and/or FADS are caused by complete or severe functional disruption of components located in the AChR pathway. We propose that whereas milder mutations of MuSK will cause a CMS phenotype, a complete loss is lethal and will cause FADS.

Three-dimensional ultrasound does not improve diagnosis of retained placental tissue compared to two-dimensional ultrasound.

The study objective was to improve ultrasonic diagnosis of retained placental tissue by measuring the volume of the uterine body and cavity using three-dimensional (3D) ultrasound. Twenty-five women who were to undergo surgical curettage due to suspected retained placental tissue were included. The volume of the uterine body and cavity was measured using the VOCAL imaging program. Twenty-one women had retained placental tissue histologically verified. Three of these had uterine volumes exceeding the largest volume observed in the normal puerperium. Seventeen of the 21 women had a uterine cavity volume exceeding the largest volume observed in the normal puerperium. In all 14 cases examined 28 days or more after delivery the cavity volume exceeded the largest volume observed in the normal puerperium. A large cavity volume estimated with 3D ultrasound is indicative of retained placental tissue. However, 3D ultrasound adds little or no diagnostic power compared to 2D ultrasound.

Longitudinal study of the uterine body and cavity with three-dimensional ultrasonography in the puerperium.

OBJECTIVE: To describe uterine involution in the puerperium with three-dimensional ultrasound. DESIGN: Prospective, longitudinal study. SETTING: Fetal medicine unit, department of obstetrics and gynecology, university referral hospital, Uppsala, Sweden. POPULATION: Fifty women with uncomplicated deliveries and puerperium between February 2009 and February 2010. METHODS: Three-dimensional ultrasound was used to measure the uterine body and cavity volumes. The volume data set was analysed using virtual organ computer-aided analysis (VOCAL) with a 30 degree rotation step. Measurements were performed transabdominally on days 1, 7 and 14 and transvaginally on days 28 and 56 postpartum. Parity, gestational age, birthweight, smoking, breastfeeding and blood loss were recorded. MAIN OUTCOME MEASURES: Uterine body and cavity volumes. RESULTS: Median uterine body volume was 756 cm(3) on day 1, 440 cm(3) on day 7, 253 cm(3) on day 14, 125 cm(3) on day 28 and 68 cm(3) on day 56. Median cavity volume was 22 cm(3) on day 1, 18 cm(3) on day 7, 6 cm(3) on day 14, 1 cm(3) on day 28 and not measurable on day 56. The interindividual variation of uterine body and cavity volumes was most pronounced on day 1 and decreased throughout the observation period. Intrauterine content was found in 36% of the women on day 1, 95% on day 7, 87% on day 14 and 28% on day 28. CONCLUSIONS: Three-dimensional ultrasound is a non-invasive tool suitable for measurement of the uterine body and cavity volumes during the puerperium. The volumes decreased in a similar pattern in the study population.

Uterine artery Doppler ultrasound in postpartum women with retained placental tissue.

We measured prospectively uterine artery Doppler flow resistance indices and looked for hyper-vascular areas in 20 patients who were to undergo surgical evacuation due to clinical and ultrasound-based suspicion of retained placental tissue (RPT). We compared these findings with those of the normal puerperium. All 20 patients underwent surgical procedures. Placental tissue was histologically confirmed in 19 patients. Mean pulsatility and mean resistance values were below the 10th percentile for eight and seven women, respectively, but overlapping was extensive. A hyper-vascular area was observed in 12 patients with histological confirmation. In eight cases, six of them with histological confirmation, no hyper-vascular area was observed. Although RPT is associated with lower resistance indices in the uterine arteries, this knowledge has limited value as a diagnostic tool for RPT. Absence of a hyper-vascular area in the myometrium does not exclude RPT, but its presence is common finding associated with RPT and should not be misinterpreted as an arterio-vascular malformation.

Longitudinal study of Doppler flow resistance indices of the uterine arteries after normal vaginal delivery.

OBJECTIVES: To measure Doppler flow resistance indices in the uterine arteries, and to observe when the early diastolic notches appear during the normal puerperium. METHODS: Some 45 women took part in this prospective longitudinal study after normal, vaginal delivery. Ultrasound examinations were scheduled for days 1, 3, 7, 14, 28 and 56 postpartum. A transabdominal probe was used during the first two postpartum weeks, and a transvaginal probe for the later examinations. The pulsatility (PI) and resistance (RI) indices in the uterine arteries were measured, and the presence or absence of early diastolic notches was recorded. RESULTS: Compared to day one, the resistance indices did not change markedly until day 28 postpartum. The mean PI was 1.23 at day 1, 1.22 at day 3, 1.22 at day 7, 1.33 at day 14, 1.81 at day 28, and 2.25 at day 56. The mean RI was 0.65 at day 1, 0.65 at day 3, 0.66 at day 7, 0.65 at day 14, 0.77 at day 28, and 0.84 at day 56. The presence of at least 1 uterine artery notch was found in 13.3% of the women at day 1, and in 90.6% at day 56 postpartum. Bilateral notches were recorded in 6.7% of the women at day 1, and in 84.4% at day 56 postpartum. CONCLUSION: Reference values of the resistance indices from uncomplicated puerperium are needed when the diagnostic efficacy of Doppler ultrasound for pathological conditions is to be tested. This study confirms that the time needed for the vascular physiology to revert from a pregnant to a non-pregnant state appears to be longer than previously assumed.

Evaluation of a sexual education intervention among Swedish high school students.

AIMS: To evaluate an intervention aimed at improving knowledge of, attitudes to, and practices regarding condoms and emergency contraception (ECP) among Swedish high school students. METHODS: An intervention study with quasi-experimental design. A strategic sample of classes from two vocational high school programs was divided into an intervention group and a comparison group. All students completed questionnaires before and after the intervention, which included sexual education lessons by a nurse-midwife and medical students, free condoms on request and access to telephone counseling. RESULTS: Of the 461 eligible students, mean age 17 years, 390 (85%) completed the pre-test and 326 (71%) the post-test. Three out of four (77%) had experienced sexual intercourse. The majority (76%) had used contraception, mostly condoms at first intercourse. The students already had good knowledge of condoms with no change after the intervention, but attitudes improved and condom use increased. Knowledge of, and attitudes towards ECP improved but use remained stable (29%). The most important source of information about ECP changed from "friends" to "school" after the intervention. More than one out of four (28%) had opted for free condoms but only 3% had requested telephone counseling. CONCLUSIONS: Condom use increased after the intervention whereas the use of ECP remained stable. Knowledge of ECP improved and the attitudes towards both condoms and ECP became more positive. Participation of nurse-midwives and medical students, skill rehearsal, and improved access to condoms may be useful elements in sexual education.

Emergency contraceptive pills over-the-counter: practices and attitudes of pharmacy and nurse-midwife providers.

Deregulation of emergency contraceptive pills (ECP) has led to pharmacy staff becoming a new provider group of ECP, together with nurse-midwives, who are already experienced in prescribing contraceptives. This postal questionnaire survey aimed to assess practices and attitudes towards ECP and the over-the-counter (OTC)-availability among pharmacy staff (n=237) and nurse-midwives (n=163). The overall response rate was 89%. Both study groups were positive to ECP and the OTC-availability and the vast majority agreed that sexually active women should be aware of ECP and that routine information about ECP should be included in contraceptive counseling. Verbal information on all aspects of ECP to clients was reported more often by nurse-midwives than by pharmacy staff. Both groups supported collaboration between providers. Our findings suggest that further collaboration between pharmacies and family planning clinics should be encouraged to ensure a competent and client-friendly provision of ECP.

Emergency contraceptive pills in Sweden: evaluation of an information campaign.

OBJECTIVE: To evaluate a community-based intervention regarding emergency contraceptive pills, including a mass media campaign and information to women visiting family planning clinics. DESIGN: Quasi-experimental. SETTING: Two counties in Sweden. POPULATION: Eight hundred randomly selected women aged 16-30 years, 400 women in the intervention group and 400 in a comparison group. METHODS: Postal questionnaires before (2002) and after (2003) the intervention. MAIN OUTCOME MEASURES: Exposure to the intervention, knowledge, attitudes, practices and intention to use emergency contraceptive pills. RESULTS: Before the intervention, the response rate was 71% (n= 564); after the intervention, the corresponding figure was 83% (n= 467); overall response rate 58%. Two-thirds (64%) of the targeted women had noticed the information campaign. One out of six who had visited a family planning clinic during the intervention year recalled being given information about emergency contraceptive pills. Specific knowledge and attitudes improved over time in both groups, but there was no difference in change between the groups. The proportion of women who had used emergency contraceptive pills increased from 27% to 31% over time. Intention to use emergency contraceptive pills in case of need was reported by 74% of the women and remained stable over time, but logistic regression showed that information during the previous year contributed to willingness to use the method in the intervention group. CONCLUSIONS: Knowledge, attitudes and practices about emergency contraceptive pills increased in both groups. Emergency contraceptive pills is gradually becoming a more widely known, accepted and used contraceptive method in Sweden, a trend that may have limited the impact of the intervention.

Emergency contraceptive pills over-the-counter: a population-based survey of young Swedish women.

One year after emergency contraceptive pills (ECP) had become prescription-free, we sent a questionnaire to 800 randomly selected women in mid-Sweden. The aim was to investigate women's knowledge, attitudes and practices regarding the method. The response rate was 71% (n = 564). The majority of the women, 65%, would prefer to purchase ECP over-the-counter (OTC) in a pharmacy. Attitudes toward the method were predominantly positive, but one fourth (24%) had worries about side effects and one third (33%) considered ECP to be a kind of abortion. Logistic regression showed that correct knowledge of and positive attitudes toward ECP contributed to estimated future use of ECP. Although women favored the OTC option, persistent misunderstanding about ECP implies that routine information from gynecologists and health professionals as well as media campaigns is needed along with the deregulation in order to make ECP an accepted and properly used contraceptive method.