Cardiotocography combined with ST analysis versus cardiotocography combined with fetal blood sampling in deliveries with abnormal CTG: a randomized trial.

PURPOSE: The aim was to investigate if intrapartum monitoring with cardiotocography (CTG) in combination with ST analysis (STAN) results in an improved perinatal outcome. METHODS: We performed a two-center randomized trial. 1013 women with term fetuses in cephalic presentation entered the trial. If a CTG showed intermediate or pathological abnormalities, they were offered fetal blood sampling (FBS) and inclusion if the pH value was above 7.25. They were randomized to either CTG + FBS or CTG + STAN. The primary outcome was neonatal metabolic acidosis, defined as umbilical cord arterial blood pH below 7.05, and base excess equal to or below -10. The secondary outcomes included operative vaginal delivery for fetal distress. RESULTS: The rate of metabolic acidosis was 0.8% in the CTG + FBS group and 1.5% in women in the CTG + STAN (P = 0.338). More women in the CTG + STAN group delivered by operative vaginal delivery (25.6% vs 33.5%, P = 0.006). Significantly fewer women in the CTG + STAN group had three to five (28.8% vs 11.0%, P = < 0.001) and six to ten fetal blood samples taken (3.4% vs 0.4%, P = < 0.001). CONCLUSION: CTG + STAN did not reduce the incidence of neonatal metabolic acidosis compared to CTG + FBS. CTG + STAN was, however, associated with an increased risk of operative vaginal delivery and a reduced use of FBS. If STAN is used for fetal surveillance, we recommend that it is combined with other methods, such as FBS, for confirmation of the need for operative delivery. CLINICALTRIALS: gov ID: NCT01699646. Date of registration: October 4, 2012 (retrospectively registered). https://clinicaltrials.gov/ct2/show/NCT01699646?id=NCT01699646&draw=2&rank=1.

Comparable risk of childhood asthma after vaginal delivery and emergency caesarean section.

INTRODUCTION: Caesarean section is thought to be a risk factor for childhood asthma, but this association may be caused by confounding from, for instance, familial factors. To address this problem, we used twin pairs to assess the risk of childhood asthma after emergency caesarean section. METHODS: The study was a register-based nation-wide matched cohort study using twin pairs to minimise residual confounding. Included were twin pairs in which the first twin was delivered vaginally and the second by emergency caesarean section during the study period from January 1997 through December 2012. RESULTS: In total, 464 twin pairs (928 twins) were included. In 30 pairs, the first twin (vaginal delivery) was diagnosed with asthma, but the second twin (emergency caesarean section) was not. In 20 pairs, the second twin (emergency caesarean section) was diagnosed with asthma, but the first twin (vaginal delivery) was not. In 11 pairs, both twins developed asthma. In the unadjusted analysis, emergency caesarean section did not affect the risk of asthma (odds ratio = 0.67 (95% confidence interval: 0.38-1.17); p = 0.16). After adjusting for birth weight, gender, umbilical cord pH, Apgar score at 5 min. and neonatal respiratory morbidity, the risk of childhood asthma following emergency caesarean section remained unchanged. CONCLUSION: Emergency caesarean section was not associated with childhood asthma. FUNDING: none. TRIAL REGISTRATION: not relevant.

Medical augmentation of labor and the risk of ADHD in offspring: a population-based study.

BACKGROUND AND OBJECTIVE: Oxytocin for labor augmentation is widely used in obstetric care in Western countries. Two recent, smaller studies found opposing results regarding the association between prenatal exposure to oxytocin for labor augmentation and attention-deficit/hyperactivity disorder (ADHD). In Denmark, oxytocin is the medication used for nearly all medical augmentations of labor, and we examined the association between medical augmentation of labor and ADHD in a large cohort study based on national register data. METHODS: All singletons born after spontaneous onset of labor in Denmark between 2000 and 2008 (N = 546 146) were included in the study. Data from the Danish Medical Birth Registry on medical augmentation of labor (yes/no) were used to identify exposed children. ADHD was defined based on the diagnostic codes of International Classification of Diseases, 10th Revision, for hyperkinetic disorder and information on dispensed ADHD medication. A multivariate proportional hazards regression model was used to test the association. RESULTS: Among 546 146 deliveries, 26% included medical augmentation of labor, and 0.9% of the children were identified as having ADHD (n = 4617). We found no association between augmentation of labor and ADHD in the offspring (hazard ratio: 1.05 [95% confidence interval: 0.98-1.13]). CONCLUSIONS: Our study does not support an association between medical augmentation of labor and ADHD in the child.

Water immersion and changes in the foetoplacental and uteroplacental circulation: an observational study with the case as its own control.

OBJECTIVE: To evaluate the effect of immersion into water on maternal blood pressure, amount of amniotic fluid and on the foetoplacental- and uteroplacental circulation in healthy women with an uncomplicated singleton pregnancy. METHODS: Twenty-five healthy women were included. Recordings of blood pressure, deepest vertical pocket of amniotic fluid and pulsatility index (PI) measured by Doppler in the umbilical and uterine arteries were obtained. The participants were immersed into water and the measurements were repeated after 5 and 25 min in water and again 15 and 30 min post immersion. RESULTS: The amount of amniotic fluid increased significantly (p < 0.001), and the maternal blood pressure decreased significantly during immersion (p < 0.001). There was no significant effect of immersion on either umbilical- or uterine artery PI. All changes returned toward baseline-level within 30 min after immersion. CONCLUSIONS: Immersion into water increases the amount of amniotic fluid and decreases the maternal blood pressure. Immersion into water has no significant effect on either the foetoplacental or uteroplacental circulation. Further studies are needed in order to explore the effect of immersion in pregnancies complicated by a dysfunctional placenta.

[Evidence-based surgical techniques for caesarean section]. / Operationsteknikker ved section.

Caesarean section (CS) is a common surgical procedure, and in Denmark 21% of deliveries is by CS. There is an increasing amount of scientific evidence to support the different surgical techniques used at CS. This article reviews the literature regarding CS techniques. There is still a lack of evidence especially about the long-term consequences of the surgical techniques.

The effect of chorionicity and twin-to-twin delivery time interval on short-term outcome of the second twin.

OBJECTIVES: To investigate the effect of chorionicity and twin-to-twin delivery time interval on short-term outcome in the second twin as well as to investigate the predictors of adverse outcome in both twins. METHODS: Data included vaginally delivered twins (≥36 weeks) from Copenhagen University Hospitals (2001-2009). The association between delivery interval and adverse outcome parameters was compared for monochorionic (MC) and dichorionic (DC) twins by multiple linear regression. Predictors were studied by logistic regression. RESULTS: There were 554 twin pairs, of which 57 were MC and 485 DC. We found no difference in the decrease of pH (p = 0.912) and Apgar (p = 0.609) in relation to increasing time interval. Neonatal unit (NICU) admissions did not differ (p = 0.167). Apgar ≤7 (p < 0.001) and pH ≤ 7.20 (p = 0.002) increased first twin risk of NICU admission, whereas first (p = 0.001) or second (p < 0.001) twin Apgar ≤7 and second twin pH ≤7.00 (p = 0.003) increased second twin risk of NICU admission. CONCLUSIONS: Increasing delivery interval was associated with a significant decrease in pH and Apgar, but there was no difference between MC and DC twins. Low Apgar of the first twin increased the risk of second twin NICU admission.

Offspring preterm birth and birth size are related to long-term risk of maternal diabetes.

The aim of the study is to investigate the association between gestational age, birth size, and the long-term risk of maternal diabetes. We conducted a nation-wide prospective follow-up study of the cohort of all Danish women with a singleton delivery in 1982/1983 (index delivery) and no history of diabetes (n = 100,669). Registries were used to extract information on patients with a hospital or outpatient diagnosis of diabetes, subsequent deliveries, and death/emigration in the period from the index delivery until the end of 2006. The association between the maternal risk of diabetes and the index gestational age and index offspring birth size (birth weight adjusted for gestational age) was investigated by using Cox proportional hazards regression models stratified according to young (≤33 years) and old age (>33 years). During a median follow-up period of 24 years, 2,021 women (2.0 %) were diagnosed as having diabetes. The risk of maternal diabetes was positively associated with increasing index birth size and negatively associated with increasing duration of index gestation in both age strata. Among young women, the highest hazard ratios were found for the exposure category of large index offspring birth size (adjusted HR 9.0, 95 % CI 6.17-13.12) and a preterm delivery at 32-37 weeks (adjusted HR 2.22, 95 % CI 1.46-3.40). Offspring preterm birth and large size for gestational age at birth are associated with increased risk of maternal diabetes.

Disclosing doubtful indications for emergency cesarean sections in rural hospitals in Tanzania: a retrospective criterion-based audit.

OBJECTIVE: To investigate in depth to what extent indications for emergency cesarean sections followed evidence-based audit criteria for realistic best practice. DESIGN: A quality assurance analysis based on a retrospective criterion-based audit. SETTING: Two rural hospitals in Tanzania. POPULATION: From 2009, 400 cesarean section instances were investigated. Of these, 303 were emergency cesarean sections and therefore included. METHODS: Documented indications for and management preceding the emergency cesarean sections were compared with the audit criteria. MAIN OUTCOME MEASURES: Prevalence of suboptimal care. RESULTS: Of the emergency sections, 26% appeared to be decided based on inappropriate indications, and in an additional 38%, the indications were unclear. Prolonged labor was the leading indication; in 36% of these, labor progressed timely and/or the membranes were still intact. In 26%, previous cesarean section was the indication, half of these with one previous section only. Fetal distress was an indication in 14%, but for 84% of these the fetal heart rate was either reassuring or not documented. For nine women, section was decided upon because of intrauterine fetal death; none had a trial of forceps/vacuum extraction or destructive surgery. CONCLUSION: A considerable number of the audited emergency cesarean sections were performed on doubtful indications. In the light of the rising trend in global cesarean section rates, there seems to be a need to ensure quality of management preceding cesarean sections. This is particularly called for in rural sub-Saharan Africa where cesarean rates are still low and health risks of emergency surgery not negligible.

Physical activity during pregnancy in obese and normal-weight women as assessed by pedometer.

OBJECTIVE: To compare physical activity as assessed by a pedometer in obese and normal-weight pregnant women at different gestational ages. To evaluate the use of a pedometer in pregnancy. DESIGN: Cross-sectional study. SETTING: Department of obstetrics and gynecology in a university hospital in Copenhagen. POPULATION: 338 pregnant women, 175 normal-weight women with body mass index (BMI) 20-25 kg/m(2) and 163 obese women with BMI > or = 30 kg/m(2). METHODS: Physical activity was assessed by a pedometer (Yamax Digiwalker SW-700/701) on seven consecutive days in six different groups: normal-weight or obese at gestational ages 11-13, 18-22, and 36-38, and expressed as median number of daily steps during a whole week, working days, and weekends. MAIN OUTCOME MEASURES: Relation between BMI and physical activity during pregnancy and compliance with wearing the pedometer. RESULTS: Noncompliance was more frequent in obese than in normal-weight women (19 vs. 10%, p < 0.001). Physical activity was lower in obese women at all gestational ages (6,482, 7,446, 4,626 steps/day in obese vs. 7,558, 8,865, 6,289 steps/day in normal-weight, p < 0.05-0.11). The greatest difference between obese and normal-weight women was seen during weekends. The level of physical activity was higher in both groups at mid-gestation than during earlier and later gestational ages. CONCLUSION: Physical activity in pregnant women can be assessed by the pedometer and the method was well accepted by the women; however, the compliance was lower in the obese. The level of physical activity differs between different gestational groups and is lower in obese than in normal-weight women, especially during leisure time.

Coffee consumption during pregnancy and the risk of hyperkinetic disorder and ADHD: a prospective cohort study.

AIM: Based on hypotheses from experimental studies, we studied the association between intrauterine exposure to coffee and the risk of clinically verified hyperkinetic disorder and attention-deficit hyperactivity disorder (ADHD). METHODS: A cohort study with prospectively collected data from the Aarhus Birth Cohort, Denmark. We included 24 068 singletons delivered between 1990 and 1998. Linkage was performed with three Danish longitudinal registers: The Danish Psychiatric Central Register, The Integrated Database for Labour Market Research and The Danish Civil Registration System. We identified 88 children with hyperkinetic disorder and ADHD. Information about coffee consumption during pregnancy was obtained at 16 weeks of gestation from self-administrated questionnaires. Potential confounding factors were evaluated using Cox regression analyses. RESULTS: We found that intrauterine exposure to 10 or more cups of coffee per day was associated with a threefold increased risk of hyperkinetic disorder and ADHD. After adjustments for a number of confounding factors, the risk decreased and became statistically insignificant (RR 2.3, 95% CI 0.9-5.9). CONCLUSION: Prenatal exposure to high levels of coffee did not significantly increase the risk of clinically verified hyperkinetic disorder and ADHD in childhood.

Peripartum hysterectomy in Denmark 1995-2004.

BACKGROUND: Severe postpartum hemorrhage (PPH) is a potentially life-threatening situation that sometimes requires a hysterectomy. We examined the national incidence, risk factors, indications, outcomes and complications of peripartum hysterectomy following vaginal and caesarean delivery. METHODS: Peripartum hysterectomy was defined as a hysterectomy after birth until 1 month after delivery using the codes for hysterectomy from the NOMESCO classification (1995). National data from the period 1995-2004 were extracted from the Danish Medical Birth Register and linked to the Danish National Hospital Register followed by registration of relevant data from the medical records of all the patients. RESULTS: We found 152 hysterectomies corresponding to an incidence of 0.24/1,000 deliveries. The risk of peripartum hysterectomy increased 11-fold following caesarean compared to vaginal delivery. Placenta accrete was present in 37% of the cases and 68%. CONCLUSION: Peripartum hysterectomy has increased significantly during the last 20 years. Optimizing treatment of PPH may decrease the incidence of peripartum hysterectomy in the future.

Psychological distress during early gestation and offspring sex ratio.

BACKGROUND: Exposure to severe stress in early pregnancy is associated with a lower male to female ratio (sex ratio), but whether more moderate levels of psychological discomfort have the same kind of effect is unknown. In a population based follow-up study, we aimed to test whether psychological distress was associated with the sex ratio in the offspring. METHODS: From 1989 to 1992, a cohort of 8,719 Danish-speaking pregnant women were followed until delivery. Questionnaires were administered to the women in early pregnancy and 6,629 (76%) completed the 30-item version of the General Health Questionnaire (GHQ). RESULTS: We found an overall male to female ratio (sex ratio) of 1.03. There was an inverse dose response association (test for trend P < 0.01) between GHQ score and sex ratio. Each 5-point increase in the GHQ score was associated with a decreasing odds of having a boy [Odds ratio (OR) = 0.93, 95% CI 0.89-0.98]. Mothers scoring in the upper quartile of the GHQ had 47% boys as compared with 52% in the undistressed groups (Risk difference =4.8%, 95% CI 1.9-7.7%) resulting in a significantly lower sex ratio of 0.85 compared with 1.07 (OR 0.82, 95% CI 0.72-0.94). CONCLUSIONS: Our results suggest that not only severe stress, but also more moderate and common levels of psychological distress, may decrease the sex ratio in the offspring. Stress during pregnancy is a likely candidate involved in the decreasing sex ratio observed in many countries.

Does fish oil prevent preterm birth?

A literature review was performed on the effect of fish oil on preterm birth in observational and randomized studies. The only weak effect on preterm birth found in meta-analyses could be caused by the low compliance, and the fact that many women stop supplementation before term together with a fast acting effect on fish oil.

Duration of pregnancy in relation to seafood intake during early and mid pregnancy: prospective cohort.

We examined the association between exposure to seafood intake during two periods of pregnancy on the one hand and risks of preterm delivery and postterm delivery on the other. In a prospective cohort of 8729 pregnant Danish women, we assessed frequency of fish meals during the first and second trimester of pregnancy by questionnaires completed around gestation weeks 16 and 30, respectively. When fish intake was based solely on intake reported for the early period of pregnancy, mean gestation length was shorter by 3.91 (95% CI: 2.24-5.58) days and odds of preterm delivery were increased 2.38 (1.23-4.61) times in those who never consumed fish (n = 308) vs. those who consumed both fish as main meal and fish in sandwiches at least once per week (n = 785). These measures were similar when fish intake was based solely on intake reported for mid-pregnancy. In the subgroup of women reporting same intake in the two trimesters, those who never consumed fish (n = 165) had 8.57 (5.46-11.7) days shorter mean gestation and 19.6 (2.32-165) times increased odds of preterm delivery, compared to high fish consumers (n = 127); odds of elective and postterm delivery were reduced by a factor 0.33 (0.11-1.02) and 0.34 (0.12-0.95), respectively, in zero fish consumers. All analyses were adjusted for potential confounding by factors such as maternal smoking, height, and prepregnant weight. We conclude that never consuming fish in the first two trimesters of pregnancy was an extremely strong risk factor for preterm delivery but was also associated with reduced risks of elective delivery and postterm delivery.

Cigarette smoking during pregnancy and hyperactive-distractible preschooler's: a follow-up study.

AIM: To study the association between intrauterine exposure to tobacco smoke and behavioural disorders in preschool children, primarily symptoms of inattention, hyperactivity and impulsivity but also hostile-aggressive and anxious-fearful symptoms. METHODS: We conducted a follow-up study in 1355 singletons born to Danish-speaking mothers. Information on smoking habits during pregnancy and other lifestyle factors was obtained from self-administered questionnaires filled in during second and third trimester. Approximately 3.5 years later, the parents provided information on their child's behaviour using the self-administered Preschool Behaviour Questionnaire. The children were categorized into three not mutually exclusive behaviour groups: hyperactive - distractible (13.6%), hostile-aggressive (4.6%), and anxious-fearful (6.4%) children. RESULTS: Compared with children of non-smokers, children born to women who smoked 10 or more cigarettes per day had a 60% increased risk of hyperactivity and distractibility perceived by the parents (OR 1.6; 95% CI 1.0-2.3; P < 0.05). The results were adjusted for maternal lifestyle factors and socioeconomic characteristics. Additional adjustment for perinatal factors and parental psychiatric hospitalization did not change the results substantially (OR 1.7; 95% CI 1.1-2.6). We found no statistically significant association between maternal smoking in pregnancy and hostile-aggressive and anxious-fearful behaviour in the offspring. CONCLUSION: Exposure to tobacco smoke in utero was associated with hyperactive-distractible behaviour in preschool children.

Prenatal exposure to cigarettes, alcohol, and coffee and the risk for febrile seizures.

OBJECTIVE: Febrile seizure is a common type of seizure in childhood, probably caused by both genetic and early environmental factors. Little is known about the effect of environmental factors that operate in prenatal life, although the fetal brain may be particular vulnerable as a result of extensive brain growth and differentiation in this period. We evaluated the association between prenatal exposure to cigarettes, alcohol, and coffee and the risk for febrile seizures in 2 population-based birth cohorts. METHODS: The Aarhus Birth Cohort consisted of 25,196 children of mothers who were scheduled to deliver at Aarhus University Hospital (1989-1996). The Aalborg-Odense cohort consisted of 10,400 children of women who attended antenatal care in Odense or Aalborg (1984-1987). Both cohorts were linked with the Danish National Hospital Register and followed until December 1998 with a complete follow-up. We extracted from medical records additional information on febrile seizures in children in the Aarhus Birth Cohort who were born between 1989 and 1992. RESULTS: We found a slightly increased risk for febrile seizures in children who were exposed to 10 or more cigarettes per day in the Aarhus Birth Cohort, but the corresponding association was weak in the Aalborg-Odense cohort. We found no association between maternal alcohol and coffee consumption and the risk for febrile seizures. The results were similar for simple and complex febrile seizures. CONCLUSIONS: Our data suggest that prenatal exposure to low to moderate levels of alcohol and coffee has no impact on the risk for febrile seizures, whereas a modest smoking effect cannot be ruled out.

Smoking during pregnancy and the risk for hyperkinetic disorder in offspring.

OBJECTIVE: Maternal smoking during pregnancy may increase the risk for behavioral disorders. The aim of this study was to investigate the association between smoking during pregnancy and hyperkinetic and attention-deficit/hyperactivity disorder in the offspring in a large population-based study. METHODS: This study was designed as a nested case-control study. Data were obtained from Danish longitudinal registers and included 170 children with hyperkinetic disorder and 3765 population-based control subjects, who were matched by age, gender, and date of birth. Potential confounders, including newborn characteristics, socioeconomic status, and family history of psychiatric illnesses, were evaluated by conditional logistic regression analyses. RESULTS: Women who smoked during pregnancy had a 3-fold increased risk for having offspring with hyperkinetic disorder compared with nonsmokers. Socioeconomic factors and history of mental disorder in the parents or siblings seemed to confound the result to some extent (adjusted relative risk: 1.9; 95% confidence interval: 1.3-2.8). Adjustment for parental age or exclusion of children with low birth weight (<2500 g), preterm delivery (<37 weeks completed gestation), and Apgar scores <7 at 5 minutes revealed no changes in the results. Also, excluding children with conduct disorders or comorbid disorders revealed no change in the results. CONCLUSIONS: Our results showed an increased risk for hyperkinetic disorder in children of mothers who smoked during pregnancy. This could not be explained by newborn characteristics, parental socioeconomic status, family history of psychiatric hospitalizations or contact as outpatients, conduct disorders, or comorbidity.

Pre-pregnancy weight and the risk of stillbirth and neonatal death.

OBJECTIVE: To evaluate the association between maternal pre-pregnancy body mass index (BMI) and the risk of stillbirth and neonatal death and to study the causes of death among the children. DESIGN: Cohort study of pregnant women receiving routine antenatal care in Aarhus, Denmark. SETTING: Aarhus University Hospital, Denmark, 1989-1996. POPULATION: A total of 24,505 singleton pregnancies (112 stillbirths, 75 neonatal deaths) were included in the analyses. METHODS: Information on maternal pre-pregnancy weight, height, lifestyle factors and obstetric risk factors were obtained from self-administered questionnaires and hospital files. We classified the population according to pre-pregnancy BMI as underweight (BMI <18.5 kg/m(2)), normal weight (BMI 18.5-24.9 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)) and obese (BMI 30.0 kg/m(2) or more). MAIN OUTCOME MEASURES: Stillbirth and neonatal death and causes of death. RESULTS: Maternal obesity was associated with a more than doubled risk of stillbirth (odds ratio = 2.8, 95% confidence interval [CI]: 1.5-5.3) and neonatal death (odds ratio = 2.6, 95% CI: 1.2-5.8) compared with women of normal weight. No statistically significantly increased risk of stillbirth or neonatal death was found among underweight or overweight women. Adjustment for maternal cigarette smoking, alcohol and caffeine intake, maternal age, height, parity, gender of the child, years of schooling, working status and cohabitation with partner did not change the conclusions, nor did exclusion of women with hypertensive disorders or diabetes mellitus. No single cause of death explained the higher mortality in children of obese women, but more stillbirths were caused by unexplained intrauterine death and fetoplacental dysfunction among obese women compared with normal weight women. CONCLUSION: Maternal obesity more than doubled the risk of stillbirth and neonatal death in our study. The present and other studies linking maternal obesity to an increased risk of severe adverse pregnancy outcomes emphasise the need for public interventions to prevent obesity in young women.

Eating disorder that was diagnosed before pregnancy and pregnancy outcome.

OBJECTIVE: The purpose of this study was to determine the association of an eating disorder that was diagnosed before pregnancy and a preterm delivery and/or the delivery of a low-birth-weight or small-for-gestational-age infant. STUDY DESIGN: This was a register-based follow-up study. We included 302 women who were hospitalized with an eating disorder before pregnancy who were delivered of 504 children and 900 control subjects who were delivered of 1552 children. The association of eating disorders, birth weight, and gestational age was assessed by bivariate and multivariate analyses. RESULTS: The risk of a low-birth-weight infant was twice as high in women with a previous eating disorder compared with women with no such disorder (odds ratio, 2.2; 95% CI, 1.4-3.2). The risk of preterm delivery and a small-for-gestational-age infant was increased to 70% and 80% (odds ratio, 1.7 [95% CI, 1.1-2.6]; odds ratio, 1.8 [95% CI, 1.3-2.4]), respectively. CONCLUSION: Women who were hospitalized for an eating disorder that was diagnosed before pregnancy were at increased risk of impaired pregnancy outcome.