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.
Population-based cohort study.
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).
In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries.
Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data.
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.
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.
An ultrasound assessment in women with placenta praevia or prior CS may double the awareness for AIP.
OBJECTIVE: Fetal urine production at different gestational ages has been evaluated using ultrasound in several previous studies. In a recent study, we investigated the accuracy when estimating the bladder volume using the conventional ultrasound technique and found a total variability of 17.3-10.9% for bladder volumes of 5-40 mL. The variability is mainly caused by: (i) inappropriate image selection (the 'freezing error') and (ii) limitations when measuring on the frozen image (the 'frozen error'). The aim of this study was to reduce the total error by reducing the 'freezing' and the 'frozen error'. To this end, we used a modified manual ultrasound technique (adding a 'rocking' motion to the conventional method) and digitized the selected image. METHODS: Two patients for each gestational week from 24 to 40 weeks were selected. The fetal urinary bladder was examined with ultrasound three times within 1 min and documented on videotape. The volume, as assessed by the longitudinal section of the recorded bladder images, stored in digitized form, was evaluated on three occasions with > 24 h in between. The mean and variability (standard deviation, SD) were estimated. RESULTS: For fetal bladder volumes between 5 and 40 mL, the 'freezing error' (SD), the 'frozen error' and the 'total error' were 11.7-5.1%, 8.0-3.0% and 14.2-5.9%, respectively. Comparing the present with a previous study, when selecting images and assessing bladder volumes repeatedly within 1 min, SD was 12.9-5.5% vs. 17.3-10.9%. CONCLUSIONS: Using a modified ultrasound technique, the variability in fetal bladder volume estimation can be reduced.
The goal of this study was to determine the prevalence and evolution of acquired right ventricular outflow tract obstruction (RVOTO) in the recipient twin in twin-twin transfusion syndrome (TTTS).
Twin-twin transfusion syndrome complicates 4% to 26% of diamniotic monochorionic twin gestations and is associated with high fetal morbidity and mortality. Cardiac dysfunction and biventricular hypertrophy may develop in the recipient twin with the potential for RVOTO.
This was a retrospective review of a two-center experience of TTTS to describe the prevalence and evolution of acquired RVOTO in the recipient twin. Right ventricular outflow tract obstruction was diagnosed or excluded by fetal or postnatal echocardiography or clinical assessment.
Of 73 twin pregnancies with TTTS identified between 1994 to 1998, a total of seven (9.6%) were complicated by RVOTO in the recipient twin: two subvalvar/muscular, four valvar and one combined. Of 44 pregnancies with fetal echo, six had in utero RVOTO with antegrade flow diagnosed at gestational ages ranging from 19 to 27 weeks. In utero progression occurred in four cases over a period of four to eight weeks, with the development of RVOT atresia by delivery. Postnatal progression of RVOTO occurred in two cases, one of which required pulmonary balloon valvuloplasty at age two years. Postnatal regression of subvalvar RVOTO occurred in two cases in early infancy. Death related directly or indirectly to the RVOTO occurred in all four patients who developed complete RVOT obliteration.
Right ventricular outflow tract obstruction may occur in the recipient twin of at least 9% of pregnancies complicated by TTTS. Right ventricular outflow tract obstruction progression is common in utero and may worsen neonatal outcome.
To predict acute psychological distress in pregnant women following detection of a fetal structural anomaly by ultrasonography, and to relate these findings to a comparison group.
A prospective, observational study.
Tertiary referral centre for fetal medicine.
One hundred and eighty pregnant women with a fetal structural anomaly detected by ultrasound (study group) and 111 with normal ultrasound findings (comparison group) were included within a week following sonographic examination after gestational age 12 weeks (inclusion period: May 2006 to February 2009).
Social dysfunction and health perception were assessed by the corresponding subscales of the General Health Questionnaire (GHQ-28). Psychological distress was assessed using the Impact of Events Scale (IES-22), Edinburgh Postnatal Depression Scale (EPDS) and the anxiety and depression subscales of the GHQ-28. Fetal anomalies were classified according to severity and diagnostic or prognostic ambiguity at the time of assessment.
Social dysfunction, health perception and psychological distress (intrusion, avoidance, arousal, anxiety, depression).
The least severe anomalies with no diagnostic or prognostic ambiguity induced the lowest levels of IES intrusive distress (P = 0.025). Women included after 22 weeks of gestation (24%) reported significantly higher GHQ distress than women included earlier in pregnancy (P = 0.003). The study group had significantly higher levels of psychosocial distress than the comparison group on all psychometric endpoints.
Psychological distress was predicted by gestational age at the time of assessment, severity of the fetal anomaly, and ambiguity concerning diagnosis or prognosis.
Acute polyhydramnios in monozygotic twin pregnancy causes severe maternal discomfort and carries a high risk of premature labor. During the years 1980 to 1987, 36 patients with this complication were delivered in Sweden, giving an incidence of 1/20,000 births, or 1/200 twin births. In 18 patients (group A) who were treated with one or more amniotic taps, the delivery was postponed by 2 weeks, as compared with one week in 18 conservatively treated patients (group B). The peri- and neonatal death rate was 47% in group A and 58% in group B. Our own experience is that amniotic taps are safe if the amniotic fluid is removed slowly under prophylactic tocolysis. It gives symptomatic relief to the mother and may postpone labor until the gestational age of the twins is more compatible with survival.
Cleft lip with or without palate (CLP) can be diagnosed antenatally through ultrasound, and may be categorised as apparently isolated versus associated with other malformations. Limited data exist on the long-term outcomes following antenatal diagnosis of apparently isolated CLP.
This study examined the long-term post-natal outcomes of CLP when found in isolation antenatally, in order to determine the rates of unexpected additional anomalies, developmental delay or genetic syndromes.
A retrospective chart review of antenatal and post-natal medical charts was completed for a ten-year period between January 2000 and December 2009. At least 2 years of available post-natal clinical information was required for inclusion in the study.
A total of 97 cases of antenatally isolated CLP were ascertained. Fifteen pregnancies were terminated. Follow-up data were available for 81 liveborns, though 4 were lost to follow-up prior to 2 years of age. Twelve of the 77 children meeting study criteria were identified to have other major malformations and/or developmental disability either later in the pregnancy or post-natally. Findings included familial clefting syndromes, trisomy 21, autism spectrum disorders, brain malformations, fetal alcohol syndrome and Kabuki syndrome, among other findings. Another 11 children had additional anomalies of minor impact. Examples of findings include a perimembranous ventricular septal defect, mild unilateral optic nerve hypoplasia, mild pulmonary artery stenosis with a small atrial septal defect, and transient delays in fine and gross motor skills. No children with clefting of the lip only had major additional diagnoses.
BACKGROUND: The aim of the present investigation was to uncover whether adverse events related to care in obstetric units have been preceded by specific health care conditions, and whether such causal relations could be classified into general categories. MATERIAL AND METHOD: The data cover 47 supervision cases within the area of pregnancy--and birth care. The cases were handled by the Norwegian Board of Health centrally (n = 32) and the Norwegian Board of Health in the counties (n = 15) in the period 2003-2006. RESULTS: Several conditions caused the adverse events. They could be classified into the four main categories: communication--and cooperation failure, uncertain lines of responsibility, lack of qualification, and weaknesses in the organization. The examination of the material disclosed that at least 2/3 of the adverse event causes could be traced back to organization of the facility and uncertain lines of responsibility. INTERPRETATION: The causes of adverse events in obstetric units are often due to circumstances over which the individual health care personnel had no control. The classification of causes into four main categories can be used as a supplement tool in the internal improvement process at departments of obstetrics.
Gestational age estimation by last menstrual period (LMP) vs. ultrasound (or best obstetric estimate in the US) may result in discrepant classification of preterm vs. term birth. We investigated whether such discrepancies are associated with adverse infant outcomes.
We studied singleton livebirths in the Medical Birth Registries of Norway, Sweden and Finland and US live birth certificates from 1999 to the most recent year available. Risk ratios (RR) with 95% confidence intervals (CI) by discordant and concordant gestational age estimation for infant, neonatal and post-neonatal mortality, Apgar score