Dose-dependent increase in risk of bleeding and bleeding complications in relation to SSRI use at delivery.

INTRODUCTION: Depression during pregnancy is a severe state that increases the risk of suicide, as well as adverse newborn outcomes. Selective serotonin re-uptake inhibitors (SSRIs) are effective for the treatment of depression, but increase the risk of bleeding complications at delivery. Knowledge on the dose dependency of this association is lacking. METHODS: A hospital-based cohort study of all women who gave birth at Karolinska University Hospital in Stockholm over the 5-year period from 2007 to 2011, with or without SSRI use, was undertaken. In total, 334 women who delivered vaginally and were exposed to SSRIs at delivery were identified. All other women who delivered vaginally formed the control group (n = 31,929). The electronic maternal health records of the 334 SSRI users were scrutinized, and the women were categorized into two groups: moderate (n = 246) or high (n = 88) SSRI dose at delivery. The main outcome was bleeding complications at delivery in relation to SSRI dose. RESULTS: A dose-dependent increase in the rate of postpartum haemorrhage (≥1000 ml) was found, affecting 8.4 %, 14.6 % and 23.9 % (p ≤ 0.001) of women in the control group, the moderate-dose group and the high-dose group, respectively. In addition, a dose-dependent increase in the rate of postpartum anaemia was found, affecting 7.0 %, 9.3 % and 15.9 % (p = 0.001) of women in the control group, the moderate-dose group and the high-dose group, respectively. Mean blood loss of 406 ml, 483 ml and 482 ml (p ≤ 0.001) was found in the control group, the moderate-dose group and the high-dose group, respectively. Women exposed to SSRIs delivered earlier, but did not have higher prevalence of pre-eclampsia compared with the control group. CONCLUSIONS: The dose-dependent relationship between SSRIs and bleeding complications may be clinically useful in the management of this vulnerable group of women.

Importance of antenatal identification of small for gestational age fetuses on perinatal and childhood outcomes: A register-based cohort study.

INTRODUCTION: Fetal growth restriction (FGR) is associated with increased risk for stillbirth, perinatal morbidity, cerebral palsy, neurodevelopmental disorders and cardiovascular disease later in life. Identifying small-for-gestational-age (SGA) fetuses is crucial for the diagnosis of FGR. The aim of this study was to investigate the association between antenatal identification of SGA fetuses and severe adverse perinatal and childhood outcome. MATERIAL AND METHODS: A register-based cohort study of all newborns delivered in Stockholm in 2014 and 2017. INCLUSION CRITERIA: singleton pregnancies without chromosomal aberrations or structural abnormalities, with a gestational age at delivery between 22+0 and 43+0 (n = 48 843). Data from childbirth records were linked to data from nationwide Swedish registers. Pregnancy including offspring data were reviewed. Adverse outcomes for non-identified and identified SGA newborns were compared using logistic regression models. Primary outcome was a composite outcome called severe adverse outcome, defined as at least one of the following: stillbirth, severe newborn distress (Apgar score <4 at 5 min, pH <7 or resuscitation activities >10 min), severe neonatal outcome (hypoxic ischemic encephalopathy 2-3, necrotizing enterocolitis, neonatal seizures, intraventricular hemorrhage grade 3-4, bronchopulmonary disease or death at <1 year), severe childhood outcome (cognitive impairment or motor impairment or cerebral palsy or hearing impairment or visual impairment or death at 1-3 years old). Secondary outcomes were stillbirth, severe newborn distress, severe neonatal outcome, severe childhood outcome. RESULTS: No association was found between antenatal identification of SGA fetuses and severe adverse outcome using the complete composite outcome (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 0.93-1.53). In subgroup analyses, non-identified SGA fetuses had an almost fivefold increased risk for stillbirth (aOR 4.79, 95% CI 2.63-8.72) and an increased risk for severe newborn distress (aOR 1.36, 95% CI 1.02-1.82), but a decreased risk for severe childhood outcome (aOR 0.63, 95% CI 0.40-0.99). No association was found between antenatal identification of SGA and severe neonatal outcome. CONCLUSIONS: Non-identified SGA fetuses have an increased risk for stillbirth and severe newborn distress. Conversely, identified SGA fetuses have an increased risk for severe childhood outcome.

Swedish obstetric thromboprophylaxis guideline: background and update.

Risk estimation concerning venous thromboembolism (VTE) and thromboprophylaxis for those at risk is routine in pregnancy. For 20 years, Swedish obstetricians have followed a weighted-risk algorithm guideline for risk estimation, based on which patient selection, timing, duration and dosage of thromboprophylaxis are determined. This article presents the latest update, the basis for the algorithm and its application for assessing moderate- to high obstetric VTE risk, defined as equal or greater absolute risk per time unit than the antepartum risk of women with one prior VTE. The risk score is based on risk factors conferring approximately fivefold increased risk of VTE or a multiple thereof. This article also presents algorithm efficacy data and describes lifestyle advice provided to patients. In our experience, the Swedish guideline for obstetric VTE risk estimation is easy to follow. It helps identify women at high risk. The risk of under- or overtreatment is thus minimised.

Cardiac Arrest Due to out-of-Hospital Pulmonary Embolism During Pregnancy: Successful Thrombolysis.

Introduction: Pulmonary embolism (PE) is a rare, severe complication in pregnancy, in which case thrombolysis can be lifesaving but has risks. We aim to highlight actions specific to pregnant women. Case Description: A 24-week pregnant woman developed shortness of breath and experienced sudden cardiac arrest. Cardiopulmonary resuscitation (CPR) was begun immediately in the ambulance and a perimortem caesarean section was performed upon arrival at hospital, but the new-born died. After 55 minutes of CPR, bedside echocardiography revealed right ventricular strain and thrombolysis was given. The uterus was bandaged to minimize blood loss. After massive transfusions and correction of haemostasis, a hysterectomy was performed due to inability of the uterus to contract. After 3 weeks, the patient was discharged in good health and placed on continuous anticoagulant treatment with warfarin. Discussion: Approximately 3% of all out-of-hospital cardiac arrest cases are due to PE. Among the few patients who survive at the scene, thrombolysis can be lifesaving and should be considered in pregnant women with unstable PE. Prompt collaborative diagnostic work-up in the emergency room is necessary. In a pregnant woman with cardiac arrest, a perimortem caesarean section improves the chances of both maternal and fetal survival. Conclusion: Thrombolysis should be considered for patients with PE in pregnancy with the same indications as in a non-pregnant woman. In case of survival, there is profuse bleeding with need for massive transfusions and haemostasis correction. Despite being in very poor condition, the above patient survived and was fully restored to health. LEARNING POINTS: In a young person with a non-shockable rhythm, pulmonary embolism should be kept in mind, especially if they have risk factors for thromboembolism, and pregnant women should be thrombolysed on the same indication as non-pregnant women.In cardiac arrest, a perimortem caesarean section improves the chances of both maternal and fetal survival, but after major surgery one should be prepared for the need for massive transfusions after thrombolysis. Bandaging the uterus might minimize bleeding. Despite 1-hour cardiac arrest with CPR, the patient survived and made a complete recovery.Lifestyle advice with exercise and sun exposure might help avoid rethrombosis and depression in both the short and long term.

The association between undetected small-for-gestational age and abnormal admission cardiotocography: A registry-based study.

OBJECTIVE: To assess the association between undetected small-for-gestational age (SGA) fetuses and abnormal admission cardiotocography (admCTG) in a low-risk population. DESIGN: An observational study. SETTING: Four hospitals in Stockholm-Gotland, Sweden. SAMPLE: A cohort of 127 461 deliveries between 1 February 2012 and 15 June 2020. METHODS: This cohort was linked to the Swedish Neonatal Quality Register. Pregnancies were designated as high or low risk at the time of admission to the labour ward according to pre-defined risk measures. SGA was defined as a birthweight at or below the tenth centile and at or below the third centile for gestational age. MAIN OUTCOME MEASURES: The main outcome was the proportion of undetected SGA by admCTG (normal or abnormal). The secondary outcome was a composite severe adverse neonatal outcome for fetuses born less than 6 hours after admission (Apgar score <4 at 5 minutes, hypoxic-ischaemic encephalopathy grade of 2-3, neonatal seizures and neonatal death). RESULTS: The rate of abnormal admCTG was 4.9%. The proportion of SGA at or below the tenth centile was higher in the abnormal admCTG group than in the normal admCTG group, 18.6% versus 9.7% (odds ratio 2.1, 95% CI 1.9-2.3). Abnormal admCTG and SGA (≤10th) was associated with a more than 20-fold increased risk of an adverse outcome compared with normal admCTG and non-SGA (adjusted odds ratio 23.7, 95% CI 9.8-57.3). The latter had a risk of 1/2000 of an adverse outcome. CONCLUSIONS: In this low-risk population, undetected SGA fetuses were more prone to having abnormal admCTG and had a substantially higher risk of severe adverse neonatal outcomes.

Is there a relation between stillbirth and low levels of vitamin D in the population? A bi-national follow-up study of vitamin D fortification.

BACKGROUND: Stillbirth has been associated with low plasma vitamin D. Both Sweden and Finland have a high proportion of low plasma vitamin D levels (< 50 nmol/L). We aimed to assess the odds of stillbirth in relation to changes in national vitamin D fortification. METHODS: We surveyed all pregnancies in Finland between 1994 and 2021 (n = 1,569,739) and Sweden (n = 2,800,730) with live or stillbirth registered in the Medical Birth Registries. The mean incidences before and after changes in the vitamin D food fortification programs in Finland (2003 and 2009) and Sweden (2018) were compared with cross-tabulation with 95% confidence intervals (CI). RESULTS: In Finland, the stillbirth rate declined from ~ 4.1/1000 prior to 2003, to 3.4/1000 between 2004 and 2009 (odds ratio [OR] 0.87, 95% CI 0.81-0.93), and to 2.8/1000 after 2010 (OR 0.84, 95% CI 0.78-0.91). In Sweden, the stillbirth rate decreased from 3.9/1000 between 2008 and 2017 to 3.2/1000 after 2018 (OR 0.83, 95% CI 0.78-0.89). When the level of the dose-dependent difference in Finland in a large sample with correct temporal associations decreased, it remained steady in Sweden, and vice versa, indicating that the effect may be due to vitamin D. These are observational findings that may not be causal. CONCLUSION: Each increment of vitamin D fortification was associated with a 15% drop in stillbirths on a national level. If true, and if fortification reaches the entire population, it may represent a milestone in preventing stillbirths and reducing health inequalities.

Incidence and outcomes of uterine rupture in women with unscarred, preterm or prelabour uteri: data from the international network of obstetric survey systems.

OBJECTIVE: Analysis of atypical cases of uterine rupture, namely, uterine rupture occurring in unscarred, preterm or prelabour uteri. DESIGN: Descriptive multi-country population-based study. SETTING: Ten high-income countries within the International Network of Obstetric Survey Systems. POPULATION: Women with unscarred, preterm or prelabour ruptured uteri. METHODS: We merged prospectively collected individual patient data in ten population-based studies of women with complete uterine rupture. In this analysis, we focused on women with uterine rupture of unscarred, preterm or prelabour ruptured uteri. MAIN OUTCOME MEASURES: Incidence, women's characteristics, presentation and maternal and perinatal outcome. RESULTS: We identified 357 atypical uterine ruptures in 3 064 923 women giving birth. Estimated incidence was 0.2 per 10 000 women (95% CI 0.2-0.3) in the unscarred uteri, 0.5 (95% CI 0.5-0.6) in the preterm uteri, 0.7 (95% CI 0.6-0.8) in the prelabour uteri, and 0.5 (95% CI 0.4-0.5) in the group with no previous caesarean. Atypical uterine rupture resulted in peripartum hysterectomy in 66 women (18.5%, 95% CI 14.3-23.5%), three maternal deaths (0.84%, 95% CI 0.17-2.5%) and perinatal death in 62 infants (19.7%, 95% CI 15.1-25.3%). CONCLUSIONS: Uterine rupture in preterm, prelabour or unscarred uteri are extremely uncommon but were associated with severe maternal and perinatal outcome. We found a mix of risk factors in unscarred uteri, most preterm uterine ruptures occurred in caesarean-scarred uteri and most prelabour uterine ruptures in 'otherwise' scarred uteri. This study may increase awareness among clinicians and raise suspicion of the possibility of uterine rupture under these less expected conditions.

Sonographic, Demographic, and Clinical Characteristics of Pre- and Postmenopausal Women with Endometrial Cancer; Results from a Post Hoc Analysis of the IETA4 (International Endometrial Tumor Analysis) Multicenter Cohort.

In this study, we conducted a comparative analysis of demographic, histopathological, and sonographic characteristics between pre- and postmenopausal women diagnosed with endometrial cancer, while also examining sonographic and anthropometric features in 'low' and 'intermediate/high-risk' cases, stratified by menopausal status. Our analysis, based on data from the International Endometrial Tumor Analysis (IETA) 4 cohort comprising 1538 women (161 premenopausal, 1377 postmenopausal) with biopsy-confirmed endometrial cancer, revealed that premenopausal women, compared to their postmenopausal counterparts, exhibited lower parity (median 1, IQR 0-2 vs. 1, IQR 1-2, p = 0.001), a higher family history of colon cancer (16% vs. 7%, p = 0.001), and smaller waist circumferences (median 92 cm, IQR 82-108 cm vs. 98 cm, IQR 87-112 cm, p = 0.002). Premenopausal women more often had a regular endometrial-myometrial border (39% vs. 23%, p < 0.001), a visible endometrial midline (23% vs. 11%, p < 0.001), and undefined tumor (73% vs. 84%, p = 0.001). Notably, despite experiencing a longer duration of abnormal uterine bleeding (median 5 months, IQR 3-12 vs. 3 months, 2-6, p < 0.001), premenopausal women more often had 'low' risk disease (78% vs. 46%, p < 0.001). Among sonographic and anthropometric features, only an irregular endometrial-myometrial border was associated with 'intermediate/high' risk in premenopausal women. Conversely, in postmenopausal women, multiple features correlated with 'intermediate/high' risk disease. Our findings emphasize the importance of considering menopausal status when evaluating sonographic features in women with endometrial cancer.

Predictive factors in pregnancies with reduced fetal movements: a pilot study.

BACKGROUND: Pregnancies with reduced fetal movements (RFM) are at risk for poor neonatal outcomes and stillbirth. AIM: To investigate whether Doppler measurements or angiogenic factors are good predictors of adverse neonatal outcomes in pregnancies with RFM. METHODS: This is a prospective pilot cohort study of 3243 women seeking care for RFM. Standard care was carried out in all cases. An extra Doppler examination was performed in 128 women to assess the flow in the middle cerebral artery, the umbilical artery, and the uterine artery. In 62/128 pregnancies, a maternal blood sample was obtained for angiogenic and antiangiogenic factors. The composite neonatal outcome of the study was one or more of the following factors: Apgar score <7 at 5', arterial aPh in the umbilical cord ≤7.1, transfer to Neonatal Intensive Care (NICU), stillbirth, and small for gestational age (SGA). RESULTS: In 14.1% (18/128) of the Doppler group and 11.7% (365/3115) of the standard care group, there was an adverse neonatal outcome (p = .51). A higher intervention rate was found in the Doppler group (28% vs. 5.4%, p < .01). The predictive model of adverse neonatal outcomes in women with RFM with angiogenic factors was 0.73 (95% CI 0.54-0.92). The area under the curve improved to 0.89 (CI 95% 0.81-0.97) when parity was added to the model. CONCLUSION: Angiogenic factors may have a place in the prediction of the neonatal outcome of RFM pregnancies. The prediction model's capacity was driven by parity. The obstetrical intervention rate increased with additional Doppler examinations.

Comparing apples and oranges? Variation in choice and reporting of short-term perinatal outcomes of term labor: A systematic review of Cochrane reviews.

Obstetric research is often criticized for using surrogate or combined outcomes with a disproportionately heavy weight of less relevant components. The objective of this methodological systematic review was to assess the choice and reporting of short-term perinatal outcomes for management of labor at or near term and evaluate if there is any need and possibility to harmonize them. A systematic methodological review of Cochrane reviews was performed. The review was registered prospectively at International Prospective Register of Systematic Reviews (PROSPERO), registration number212954. The Cochrane Database of Systematic Reviews was searched by topics and group browsing and by combination of free-text words and standardized subject terms. Cochrane Systematic Reviews with focus on management of labor at or near term, including timing, type of labor onset, mode of delivery and intrapartum care were included while those focused on prenatal care, postnatal interventions, and preterm deliveries were excluded. Prespecified and reported non-prespecified short-term perinatal (foetal and newborn) outcomes were collected. The outcomes were grouped into domains and classified independently by two authors into five prespecified groups regarding their anticipated importance for patients. Outcomes reflecting how a patient feels, functions, and survives were deemed patient-important. We also evaluated whether any of the outcomes were salutogenic (reflecting positive health and well-being rather than illness or adverse event prevention or avoidance). Our search resulted in 806 Cochrane Systematic Reviews, of which we included 141 published between the years 1996 and 2020. We identified 348 unique outcomes, of which 15 (4.3%) were prespecified and 13 (3.7%) were reported in at least 10% of the reviews. Only half of the prespecified outcomes were reported. In total, 88 (25.3%) of the 348 outcomes were classified as patient important, reflecting how a patient feels, functions, and survives. Salutogenic outcomes were rare (3.4%). To conclude, variation in the choice of outcomes for management of term labor as well as the discrepancy between chosen and reported outcomes were large. Harmonization of perinatal outcome measures, based on consensus between researchers, clinicians, and families, is needed.

Sun Exposure - Hazards and Benefits.

There are carcinogenic effects of sun exposure that increase the risk for skin cancer, especially for fair-skinned individuals. Therefore, there are recommendations to avoid sun exposure and to apply sun blockers. A more nuanced and balanced message for sun safety guidelines is now advocated. Despite an increased risk of death due to skin cancer, fair skinned women seem to have an overall survival advantage. In addition, an inverse association between sun exposure and hypertension, thromboembolism, and type 2 diabetes mellitus has been shown. Furthermore, low sun exposure habits result in increased risk of cardiovascular disease (CVD), and non-CVD/non-cancer mortality among women. There are also data supporting that the prognosis of cancer is improved with increasing levels of vitamin D/sun exposure. In this narrative review we will provide a brief update of hazards and benefits of sun exposure focused on an updated, balanced, and evidence-based view.

Variable deceleration features and intrapartum fetal acidemia - The role of deceleration area.

OBJECTIVE: In recent years deceleration area has received increasing attention as a potential predictor of intrapartum fetal hypoxia. In several studies, the area has been manually esteemed as triangular in shape, which might introduce bias. In addition, the commonly used outcome acidemia in umbilical artery is affected by mode of delivery. We wanted to investigate the association between the variable deceleration features area, duration, depth and cumulative deceleration area (30 and 60 min) and intrapartum fetal acidemia measured as lactate concentration at fetal scalp blood sampling (FBS) in immediate connection to the decelerations. STUDY DESIGN: In the source population of 1070 labors at Karolinska University Hospital, Sweden, with FBS performed on indication, we found 507 fetuses with predominantly variable decelerations as the indication for FBS. We examined the last 60- and 30-minutes of fetal monitoring preceding the FBS with focus on deceleration area, duration and depth. The contours of the decelerations were outlined manually but the area was calculated with a computer software program. We assessed area, duration and depth both as mean values per deceleration and as cumulative values during the time period of interest. We analyzed Pearson correlations and area under receiver operating characteristics curves (AUC). We also performed an adjusted analysis, with baseline frequency, variability, and accelerations as covariates. RESULTS: Deceleration area and duration were the best predictors of intrapartum fetal acidemia (fetal lactate concentration >4.8 mmol/L measured with Lactate Pro™) with AUCs of 0.671 (0.682) and 0.678 (0.683) for cumulative measures during 30 (60) minutes prior to FBS, compared to deceleration depth with AUC of 0.632 (0.631). Corresponding Pearson correlations in 30-min (60-min) groups were 0.329 (0.335) and 0.358 (0.354) for deceleration area and duration and 0.212 (0.204) for deceleration depth. Using 250 beats cumulative cut-off for deceleration area during last 30 min, 71% vs. 43% were acidemic and non-acidemic, odds ratio = 3.2 (95% CI 1.7-6.1). CONCLUSIONS: Deceleration area and duration were better predictors of intrapartum fetal acidemia than deceleration depth. Cumulative deceleration area >250 beats during 30 min was associated with three-fold higher odds of intrapartum acidemia compared to <250 beats.

Management of major obstetric hemorrhage prior to peripartum hysterectomy and outcomes across nine European countries.

INTRODUCTION: Peripartum hysterectomy is applied as a surgical intervention of last resort for major obstetric hemorrhage. It is performed in an emergency setting except for women with a strong suspicion of placenta accreta spectrum (PAS), where it may be anticipated before cesarean section. The aim of this study was to compare management strategies in the case of obstetric hemorrhage leading to hysterectomy, between nine European countries participating in the International Network of Obstetric Survey Systems (INOSS), and to describe pooled maternal and neonatal outcomes following peripartum hysterectomy. MATERIAL AND METHODS: We merged data from nine nationwide or multi-regional obstetric surveillance studies performed in Belgium, Denmark, Finland, France, Italy, the Netherlands, Slovakia, Sweden and the UK collected between 2004 and 2016. Hysterectomies performed from 22 gestational weeks up to 48 h postpartum due to obstetric hemorrhage were included. Stratifying women with and without PAS, procedures performed in the management of obstetric hemorrhage prior to hysterectomy between countries were counted and compared. Prevalence of maternal mortality, complications after hysterectomy and neonatal adverse events (stillbirth or neonatal mortality) were calculated. RESULTS: A total of 1302 women with peripartum hysterectomy were included. In women without PAS who had major obstetric hemorrhage leading to hysterectomy, uterotonics administration was lowest in Slovakia (48/73, 66%) and highest in Denmark (25/27, 93%), intrauterine balloon use was lowest in Slovakia (1/72, 1%) and highest in Denmark (11/27, 41%), and interventional radiology varied between 0/27 in Denmark and Slovakia to 11/59 (79%) in Belgium. In women with PAS, uterotonics administration was lowest in Finland (5/16, 31%) and highest in the UK (84/103, 82%), intrauterine balloon use varied between 0/14 in Belgium and Slovakia to 29/103 (28%) in the UK. Interventional radiology was lowest in Denmark (0/16) and highest in Finland (9/15, 60%). Maternal mortality occurred in 14/1226 (1%), the most common complications were hematologic (95/1202, 8%) and respiratory (81/1101, 7%). Adverse neonatal events were observed in 79/1259 (6%) births. CONCLUSIONS: Management of obstetric hemorrhage in women who eventually underwent peripartum hysterectomy varied greatly between these nine European countries. This potentially life-saving procedure is associated with substantial adverse maternal and neonatal outcome.

Low sun exposure habits is associated with a dose-dependent increased risk of hypertension: a report from the large MISS cohort.

In prospective observational cohort studies, increasing sun exposure habits have been associated with reduced risk of cardiovascular mortality. Our aim was to assess possible observational mechanisms for this phenomenon. A written questionnaire was answered by 23,593 women in the year 2000 regarding risk factors for melanoma, including factors of possible interest for hypertension, such as detailed sun exposure habits, hypertension, marital status, education, smoking, alcohol consumption, BMI, exercise, and chronic high stress. Hypertension was measured by the proxy "use of hypertension medication" 2005-2007, and high stress by "need of anti-depressive medication". Sun exposure habits was assessed by the number of `yes' to the following questions; Do you sunbath during summer?, During winter vacation?, Do you travel south to sunbath?, Or do you use sun bed? Women answering 'yes' on one or two questions had moderate and those answering 'yes' on three or four as having greatest sun exposure. The main outcome was the risk of hypertension by sun exposure habits adjusted for confounding. As compared to those women with the greatest sun exposure, women with low and moderate sun exposure were at 41% and 15% higher odds of hypertension (OR 1.41, 95% CI 1.3‒1.6, p < 0.001 and OR 1.15, 95% CI 1.1‒1.2, p < 0.001), respectively. There was a strong age-related increased risk of hypertension. Other risk factors for hypertension were lack of exercise (OR 1.36), a non-fair phenotype (OR 1.08), chronic high stress level (OR 1.8), and lack of university education (OR 1.3). We conclude that in our observational design sun exposure was associated with a dose-dependent reduced risk of hypertension, which might partly explain the fewer deaths of cardiovascular disease with increasing sun exposure.

Antenatal awareness and obstetric outcomes in large fetuses: A retrospective evaluation.

INTRODUCTION: There is currently no consensus on the management of large fetuses in order to minimize fetal complications. The aim of this study was to assess whether antenatal recognition of large-for-gestational age (LGA) reduced poor obstetric newborn outcomes in a hospital where expectant management was used. MATERIAL AND METHODS: A retrospective cohort study was made of two delivery units at Karolinska University Hospital, Stockholm, Sweden, using expectant management of LGA. All deliveries > 37+0 weeks of gestation during an 8-year period (2002-2009) were included. The main outcome was severe adverse outcome, a composite variable including neonatal trauma (brachial plexus birth palsy [BPBP] and fractures) and asphyxic sequelae (severe asphyxia, cerebral damage, and fetal/infant death). RESULTS: The study population consisted of 63,542 appropriate-for-gestational age (AGA) and 3,343 LGA pregnancies (of which 21 % were identified before delivery). Compared to AGA, LGA pregnancies showed a five-fold increased risk of neonatal trauma (OR 5.1, 95 % CI 4.0 - 6.4), but no differences were seen regarding asphyxic sequelae. LGA fetuses identified antenatally had adverse outcomes in 3.7 % of all cases, compared to 3.5 % where LGA was not identified (OR 1.07 95 % CI 0.7 - 1.7). When adjusted for newborn weight deviation, the OR was 0.96, 95 % CI 0.6 - 1.5. There was a three-fold higher risk (OR 3.0, 95 % CI 1.2 - 7.4) of neonatal trauma among non-identified LGA cases > 41+0 gestational weeks. A total of 81 % of those with LGA were identified after a week 41 routine ultrasound. Out of 68 cases with planned vaginal delivery and expected birth weight > 5000 g, 7.4 % suffered BPBP, representing a 31-fold increase in risk, compared to 0% BPBP among those delivered by elective caesarean section. CONCLUSION: Antenatal awareness of LGA did not lower the risk of severe adverse outcomes in a unit using expectant management, but those identified postdate were at a lower risk of neonatal trauma. For every 14 fetuses with an expected birth weight > 5000 g delivered by cesarean section, one case of BPBP could be avoided.

External cephalic version for breech presentation: The guideline landscape and a quest for an optimal approach.

OBJECTIVES: The aim of this study was to illuminate differences in guidelines for external cephalic version (ECV) for breech presentation at or near term and assess their impact on effectiveness of the procedure in order to improve policymaking. STUDY DESIGN: Guidelines from all Swedish ECV providers (hospitals with labor wards, n = 44) were retrieved in 2019 and assessed for similarities and differences. The scoring system based on the identified differences in timing, contraindications and periprocedural care was created. The hospitals were subsequently classified into either restrictive or liberal with regard to ECV. This classification was verified by comparing selection of patients for ECV attempts between the two groups. Our main outcomes were ECV success rate and effectiveness in reducing the remaining breech births and breech cesarean sections. RESULTS: Important differences in timing of ECV, contraindications, periprocedural care, and counselling after failed ECV attempt were found. Two thirds of the hospitals were considered liberal and one third restrictive with regard to ECV. ECV success rate was significantly higher in hospitals with a liberal attitude towards ECV compared with restrictive hospitals (54.0 % vs 50.5 %, p = 0.015). Liberal hospitals had a significantly lower proportion of remaining breech births (2.81 % vs 3.01 %, p = 0.009) and breech cesarean sections at or near term (2.49 % vs 2.72 %, p = 0.003). CONCLUSION: Important differences in ECV guidelines were found. Hospitals with guidelines reflecting a liberal attitude to ECV had a higher ECV success rate, despite a less strict patient selection, and a lower proportion of breech births and breech cesarean sections, which is the aim of ECV. We recommend avoiding routine ill-founded restrictivity in ECV guidelines and support a more nuanced counselling.

On the Relationship Between Sun Exposure and All-Cause Mortality.

Increasing sun exposure is related to lower prevalence of death in cardiovascular disease (CVD), type 2 diabetes, and other noncancer non-CVD. In this chapter we aim to make a short update on the knowledge regarding sun exposure and all-cause mortality. Data support the hypothesis that low sun exposure habits are a major risk factor for all-cause mortality. Low sun exposure is related to an increased risk of death due to CVD and noncancer/non-CVD, and a minor reduction in risk of cancer. Active sun exposure habits have a dual effect; it increases the incidence of skin cancer, but also improves the prognosis in terms of all-cause mortality. In a low solar intensity region, we should carefully assess both risk and benefits of sun exposure in order to obtain balanced recommendations.

Insufficient Sun Exposure Has Become a Real Public Health Problem.

This article aims to alert the medical community and public health authorities to accumulating evidence on health benefits from sun exposure, which suggests that insufficient sun exposure is a significant public health problem. Studies in the past decade indicate that insufficient sun exposure may be responsible for 340,000 deaths in the United States and 480,000 deaths in Europe per year, and an increased incidence of breast cancer, colorectal cancer, hypertension, cardiovascular disease, metabolic syndrome, multiple sclerosis, Alzheimer's disease, autism, asthma, type 1 diabetes and myopia. Vitamin D has long been considered the principal mediator of beneficial effects of sun exposure. However, oral vitamin D supplementation has not been convincingly shown to prevent the above conditions; thus, serum 25(OH)D as an indicator of vitamin D status may be a proxy for and not a mediator of beneficial effects of sun exposure. New candidate mechanisms include the release of nitric oxide from the skin and direct effects of ultraviolet radiation (UVR) on peripheral blood cells. Collectively, this evidence indicates it would be wise for people living outside the tropics to ensure they expose their skin sufficiently to the sun. To minimize the harms of excessive sun exposure, great care must be taken to avoid sunburn, and sun exposure during high ambient UVR seasons should be obtained incrementally at not more than 5-30 min a day (depending on skin type and UV index), in season-appropriate clothing and with eyes closed or protected by sunglasses that filter UVR.