Decreasing mortality during pregnancy and for a year after while mortality after termination of pregnancy remains high: a population-based register study of pregnancy-associated deaths in Finland 2001-2012.

OBJECTIVE: To investigate mortality in the non-pregnant fertile female population, and mortality during pregnancy and up to 1 year after the end of pregnancy, in Finland from 2001 to 2012 and compare the results with those of 1987-2000. DESIGN: Retrospective cohort study. SETTING: Finland. POPULATION: 10 427 deceased women of reproductive age (15-49). METHODS: Pregnancy outcomes were categorised into: ongoing pregnancy or birth, miscarriage or ectopic pregnancy and termination of pregnancy. Mortality was calculated per 100 000 pregnancies. The mortality rate of the non-pregnant female population of fertile age was calculated per 100 000 person-years, and the results were compared with those of 1987-2000. MAIN OUTCOME MEASURES: Pregnancy-associated mortality during pregnancy and up to 1 year after the end of pregnancy. Mortality of non-pregnant, fertile-age, female population. RESULTS: The age-adjusted mortality rate during pregnancy and within 1 year after the end of pregnancy was 28.4/100 000 pregnancies, and it had significantly decreased compared with the period 1987-2000 [risk ratio (RR) 0.75 (95% CI, 0.65-0.88)]. Mortality in non-pregnant fertile-age females was 48.1/100 000 person-years. Mortality for diseases and medical conditions during and after pregnancy decreased by 26% [RR 0.74 (95% CI, 0.59-0.92)] and for external causes by 23% [RR 0.77 (95% CI, 0.62-0.95)]. The mortality rate for suicides was 3.3/100 000 in ongoing pregnancies and pregnancies ending in birth while it was 21.8/100 000 after termination of pregnancy and 10.2/100 000 among non-pregnant women. CONCLUSIONS: In comparison with earlier decades, pregnancy-associated mortality has decreased in Finland. TWEETABLE ABSTRACT: Mortality decreases among pregnant women and within 1 year after pregnancy in Finland.

Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries.

OBJECTIVE: The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries. DESIGN: Population-based cohort study. SETTING AND POPULATION: A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS). METHODS: In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries. MAIN OUTCOME MEASURES: Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data. RESULTS: A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia. CONCLUSION: Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP. TWEETABLE ABSTRACT: An ultrasound assessment in women with placenta praevia or prior CS may double the awareness for AIP.

Determining obstetric patient safety indicators: the differences in neonatal outcome measures between different-sized delivery units.

OBJECTIVE: To study the differences in neonatal outcome and treatment measures in Finnish obstetric units. DESIGN: A registry study with Medical Birth Register data. SETTING AND POPULATION: All births (n = 2 94 726) in Finland from 2006 to 2010 with a focus on term, singleton non-university deliveries. METHODS: All 34 delivery units were grouped into small (below 1000), mid-sized (1000-2999) and large (3000 or more) units, and the adverse outcome rates in neonates were compared using logistic regression. MAIN OUTCOME MEASURES: Early neonatal deaths, stillbirths, Apgar scores, arterial cord pH, Erb's paralysis, respirator treatment, the proportion of post-term deliveries (gestational age beyond 42 weeks) and the proportion of newborns still hospitalised 7 days after delivery. RESULTS: From an analysis of term, singleton non-university deliveries, the early neonatal mortality was significantly higher in the small relative to the mid-sized delivery units [odds ratio (OR), 2.07; 95% confidence interval (CI), 1.19-3.60]. The rate of Erb's paralysis was lowest in the large units (OR, 0.65; 95% CI, 0.50-0.84). The use of a respirator was more than two-fold more common in large relative to mid-sized units (OR, 2.38; 95% CI, 2.00-2.83). The proportion of post-term deliveries was highest in the large units (OR, 1.36; 95% CI, 1.31-1.42), where a significantly higher percentage of post-term newborns were still hospitalised after 7 days (OR, 1.50; 95% CI, 1.19-1.89). CONCLUSIONS: There are significant differences in several neonatal indicators dependent on the hospital size. An international consensus is needed on which indicators should be used.

Colposcopy referral rate can be reduced by high-risk human papillomavirus triage in the management of recurrent atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion cytology in Finland.

The aim of this study was to establish whether a combination of high-risk human papillomavirus (hrHPV) testing and cervical cytology could reduce colposcopy referral among women with atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion cytology. We randomized 598 women in the Helsinki area, Finland into three study groups. Different strategies of hrHPV testing, cytology and colposcopy with biopsy were used; subsequent hrHPV test results and cytological findings were compared with histology. The rates of hrHPV positivity and CIN2+ were compared. In total, 62.5% of all samples were hrHPV-positive. Altogether 45 (12.7%) CIN2 or worse (CIN2+) lesions were found in study groups A and B. Among hrHPV-positive women the rate of CIN2+ was 19.0% (n = 43), in contrast with 1.6% (n = 2) among hrHPV-negative women (relative risk = 12.2, 95% confidence interval [CI] 3.6-81.1, P < 0.001). Among all hrHPV-negative women whose cytological findings were normal or ASCUS, dysplastic lesions were uncommon (n = 4/119, 3.4%), and all were CIN1. If these women had not been referred to colposcopy, the number of colposcopies would have been reduced by 33.6%. We conclude that hrHPV testing combined with repeat cervical cytology had a high negative predictive value in patients with recurrent low-grade cervical cytology. This could reduce the referral rate to colposcopy without jeopardizing patient safety.

Long-term mortality in women treated for cervical intraepithelial neoplasia.

OBJECTIVE: The objective of this study was to study whether women surgically treated for cervical intraepithelial neoplasia (CIN) have increased mortality later in life. We also wanted to study whether pregnancy beyond 22 weeks post-treatment affects the risk. DESIGN: Register-based retrospective cohort study from Finland. SETTING: National data of the Hospital Discharge Register and the Cause-of-Death Register during 1986-2003. POPULATION: A total of 25 827 women who had surgical treatment for CIN during 1986-2003. METHODS: We calculated standardised mortality ratios (SMRs) by dividing the numbers of observed deaths (until 31 December 2006) by the numbers of expected deaths. MAIN OUTCOME MEASURES: SMRs for different causes-of-death groups. RESULTS: The overall mortality increased by 17% after treatment for CIN, including increased risk of dying from all diseases and medical conditions (SMR 1.13, 95% CI 1.01-1.26), cancers (SMR 1.09, 95% CI 0.91-1.27) and injury deaths (SMR 1.31, 95% CI 1.03-1.58). As expected, the mortality from cervical cancer was high (SMR 7.69, 95% CI 4.23-11.15). Women who had delivered post-treatment tended to have decreased overall mortality (SMR 0.78, 95% CI 0.52-1.04) and decreased disease mortality (SMR 0.63, 95% CI 0.37-0.90). However, the mortality rate was significantly increased for women who had subsequent preterm delivery (SMR 2.51, 95% CI 1.24-3.78). In this subgroup, there was a tendency of increased mortality from diseases of the circulatory system, alcohol-related causes and injury deaths. CONCLUSIONS: Mortality rate was increased after surgical treatment for CIN. However, women who had delivered post-treatment had decreased overall disease mortality rate. Subsequent preterm delivery may be a risk marker for increased long-term mortality.

The incidence of preterm deliveries decreases in Finland.

OBJECTIVE: We examined the trends and risk factors of preterm delivery. DESIGN: Register-based retrospective cohort study from Finland. SETTING: National Medical Birth Register data during 1987-2005. POPULATION: The study population consisted of 1 137 515 deliveries, of which 59 025 were preterm (5.2%). METHODS: We calculated the population attributable risks for using the risk factor prevalence rates in the population. We further calculated odds ratios with 95% CI by multivariate logistic regression to adjust for confounders. MAIN OUTCOME MEASURES: Preterm delivery rate subclassified into moderately preterm (32-36 weeks), very preterm (28-31 weeks) and extremely preterm (less than 28 weeks). RESULTS; Preterm delivery rates increased from 5.1% in the late 1980s to 5.4% in the late 1990s but then decreased to 5.2% for 2001-05. The proportion of extremely preterm deliveries decreased substantially by 12% (P < 0.01). The greatest risk factors were multiplicity (OR 13.72, 95% CI 13.26-14.19), followed by elective delivery (OR 1.86, 95% CI 1.82-1.89), primiparity (OR 1.47, 95% CI 1.45-1.50), in vitro fertilisation treatment (OR 1.39, 95% CI 1.31-1.47), maternal smoking (OR 1.31, 95% CI 1.29-1.34) and advanced maternal age (OR 1.02, 95% CI 1.02-1.03 for each additional year of age). Prematurity rates decreased by 1.8% after adjusting for risk variables. CONCLUSIONS: The rate of preterm delivery has not increased from 1987 to 2005 in Finland, while the risk for extremely preterm delivery has decreased. This finding is in contrast with recent trends in other countries.

Experience with isotonic 2.2% glycine as distension medium for hysteroscopic endomyometrial resection.

The feasibility of performing hysteroscopic endomyometrial resection using isotonic 2.2% glycine as distension medium was studied in 181 consecutive operations. A standard continuous flow loop-resectoscope was used. Distension was achieved by means of a gravity-fed system and glycine flowed out under its own pressure. The mean (+/-SEM) glycine deficit was 160+/-20 ml and in only 7 patients was it >1 liter (maximum 1,800 ml). Only in patients with >1 liter glycine absorption was there a significant decrease in serum sodium level (mean 9 mmol/l), while serum osmolality remained normal. Apart from 1 case of transient nausea, these patients had no sequelae. We experienced isotonic 2.2% glycine as a useful and safe distending medium for operative hysteroscopy.

Comparison of hysteroscopic endometrial resection and laparoscopic assisted vaginal hysterectomy for the treatment of menorrhagia.

BACKGROUND: To compare the advantages and disadvantages of the two endoscopic procedures, hysteroscopic endometrial resection and laparoscopic assisted vaginal hysterectomy (LAVH), in the treatment of menorrhagia. METHODS: Forty women requiring surgical treatment for menorrhagia underwent LAVH. These women were compared retrospectively with forty women having had endometrial resection for menorrhagia. The operations were performed between November 1991 and February 1995. RESULTS: Operating time, hospitalization and postoperative recovery were significantly shorter with endometrial resection than with LAVH. In the hysteroscopy group amenorrhea or hypomenorrhea was achieved in 80% of cases. Hysterectomy was performed in two cases (5%). In the hysteroscopy group all but three women (92%) were satisfied with the procedure, in the LAVH group all but one (97%). CONCLUSIONS: In the surgical treatment of menorrhagia both procedures are effective. LAVH is associated with a longer recovery period, but it offers a permanent relief of menorrhagia. Even though endometrial resection does not render all women treated amenorrhoic, the satisfaction rate during the follow-up period was high; it is a useful alternative with many short-term benefits.

Hysteroscopic endomyometrial resection for the treatment of menorrhagia--follow-up of 86 cases.

OBJECTIVE: The aim of the study was to determine the effectiveness of hysteroscopic endomyometrial resection in the treatment of menorrhagia. STUDY DESIGN: Eighty-six women with menorrhagia underwent hysteroscopic endomyometrial resection between November 1990 and November 1993. The surgery was carried out under spinal anesthesia in 54 (64%) of the patients. A standard resectoscope was used and the uterine cavity distended with 2.2% glycine. The mean follow-up period was 22 months (range 4-39). RESULTS: No major complications occurred and no fluid overload was reported. One episode of uterine perforation, one of pelvic infection, five episodes of postspinal headache and four of hematometra were recorded. Hysterectomy was performed in five cases. Follow-up information was available on 79 (92%) patients. Amenorrhea was achieved in 20 (25%) patients and hypomenorrhea in 44 (56%) patients. Only three (4%) patients showed no improvement in menstrual flow. CONCLUSIONS: Hysteroscopic endomyometrial resection is a safe and effective mode of treatment for menorrhagia in selected patients.