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Place K, Rahkonen L, Tekay A, Väyrynen K, Orden M, Vääräsmäki M, Uotila J, Tihtonen K, Rinne K, Mäkikallio K, Heinonen S, Kruit H. Labor induction at 41 +0 gestational weeks or expectant management for the nulliparous woman: The Finnish randomized controlled multicenter trial. Acta Obstet Gynecol Scand 2024; 103:505-511. [PMID: 38112629 PMCID: PMC10867371 DOI: 10.1111/aogs.14755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/18/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION Neonatal and maternal risks increase in term pregnancy as gestational age advances and become increasingly evident post-term. Management practices of late- and post-term pregnancies vary, and the optimal time point for intervention by labor induction is yet to be determined. MATERIAL AND METHODS This randomized controlled trial of 381 nulliparous women with unripe cervices compared labor induction at 41+0 gestational weeks (early induction) with expectant management and labor induction at 41+5 to 42+1 gestational weeks (expectant management). This multicenter study included all five university hospitals and the largest central hospital in Finland. The study period was 2018-2022. Participants were randomized to either early induction (48.8%, n = 186) or expectant management (51.2%, n = 195) with equal randomization ratios of 1:1. This was a superiority trial, and the primary outcomes were rates of cesarean section (CS) and composite of adverse neonatal outcomes. The trial was registered at the ISRCTN registry (ISRCTN83219789, https://doi.org/10.1186/ISRCTN83219789). RESULTS The rates of CS (16.7% [n = 31] vs. 24.1% [n = 47], RR 0.7 [95% CI: 0.5-1.0], p = 0.07) and a composite of adverse neonatal outcomes (9.7% [n = 18] vs. 14.4% [n = 28], RR 0.7 [95% CI: 0.4-1.2] p = 0.16) did not significantly differ between the groups, but the operative delivery rate was lower in the early induction group than in the expectant management group (30.6% [n = 57] vs. 45.6% [n = 89], p = 0.003). The rates of hemorrhage ≥1000 mL and neonatal weight ≥4000 g were also lower in the early induction group, as was the vacuum extraction rate in women with vaginal delivery. Of the women with expectant management, 45.6% (n = 89) had spontaneous onset of labor. No perinatal deaths occurred, but one case of eclampsia appeared in the expectant management group. CONCLUSIONS Offering labor induction to nulliparous women at 41+0 gestational weeks may decrease the probability of operative delivery, postpartum hemorrhage, and neonatal weight ≥4000 g. However, this study was underpowered to affirm the trends of rising rates of CS and adverse neonatal outcomes in the expectant management group. Thus, expectant management could remain an option for some, as one in two women with expectant management had a spontaneous onset of labor.
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Affiliation(s)
- Katariina Place
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Leena Rahkonen
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Aydin Tekay
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Kirsi Väyrynen
- Department of Obstetrics and GynecologyCentral Finland Central HospitalJyväskyläFinland
| | - Maija‐Riitta Orden
- Department of Obstetrics and GynecologyKuopio University Hospital and University of Eastern FinlandKuopioFinland
| | - Marja Vääräsmäki
- Clinical Medicine Research Unit, Department of Obstetrics and Gynecology, Medical Research Center OuluOulu University Hospital and University of OuluOuluFinland
| | - Jukka Uotila
- Department of Obstetrics and GynecologyTampere University Hospital and Tampere UniversityTampereFinland
| | - Kati Tihtonen
- Department of Obstetrics and GynecologyTampere University Hospital and Tampere UniversityTampereFinland
| | - Kirsi Rinne
- Department of Obstetrics and GynecologyTurku University Hospital and University of TurkuTurkuFinland
| | - Kaarin Mäkikallio
- Department of Obstetrics and GynecologyTurku University Hospital and University of TurkuTurkuFinland
| | - Seppo Heinonen
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Heidi Kruit
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
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2
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Ekman-Ordeberg G, Hellgren-Wångdahl M, Jeppson A, Rahkonen L, Blomberg M, Pettersson K, Bejlum C, Engberg M, Ludvigsen M, Uotila J, Tihtonen K, Hallberg G, Jonsson M. Tafoxiparin, a novel drug candidate for cervical ripening and labor augmentation: results from 2 randomized, placebo-controlled studies. Am J Obstet Gynecol 2024; 230:S759-S768. [PMID: 38462256 DOI: 10.1016/j.ajog.2022.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 03/12/2024]
Abstract
BACKGROUND Slow progression of labor is a common obstetrical problem with multiple associated complications. Tafoxiparin is a depolymerized form of heparin with a molecular structure that eliminates the anticoagulant effects of heparin. We report on 2 phase II clinical studies of tafoxiparin in primiparas. Study 1 was an exploratory, first-in-pregnant-women study and study 2 was a dose-finding study. OBJECTIVE Study 1 was performed to explore the effects on labor time of subcutaneous administration of tafoxiparin before onset of labor. Study 2 was performed to test the hypothesis that intravenous treatment with tafoxiparin reduces the risk for prolonged labor after spontaneous labor onset in situations requiring oxytocin stimulation because of dystocia. STUDY DESIGN Both studies were randomized, double-blind, and placebo-controlled. Participants were healthy, nulliparous females aged 18 to 45 years with a normal singleton pregnancy and gestational age confirmed by ultrasound. The primary endpoints were time from onset of established labor (cervical dilation of 4 cm) until delivery (study 1) and time from start of study treatment infusion until delivery (study 2). In study 1, patients at 38 to 40 weeks of gestation received 60 mg tafoxiparin or placebo daily as 0.4 mL subcutaneous injections until labor onset (maximum 28 days). In study 2, patients experiencing slow progression of labor, a prolonged latent phase, or labor arrest received a placebo or 1 of 3 short-term tafoxiparin regimens (initial bolus 7, 21, or 35 mg followed by continuous infusion at 5, 15, or 25 mg/hour until delivery; maximum duration, 36 hours) in conjunction with oxytocin. RESULTS The number of participants randomized in study 1 was 263, and 361 were randomized in study 2. There were no statistically significant differences in the primary endpoints between those receiving tafoxiparin and those receiving the placebo in both studies. However, in study 1, the risk for having a labor time exceeding 12 hours was significantly reduced by tafoxiparin (tafoxiparin 6/114 [5%] vs placebo 18/101 [18%]; P=.0045). Post hoc analyses showed that women who underwent labor induction had a median (range) labor time of 4.44 (1.2-8.5) hours with tafoxiparin and 7.03 (1.5-14.3) hours with the placebo (P=.0041) and that co-administration of tafoxiparin potentiates the effect of oxytocin and facilitates a shorter labor time among women with a labor time exceeding 6 to 8 hours (P=.016). Among women induced into labor, tafoxiparin had a positive effect on cervical ripening in 11 of 13 cases (85%) compared with 3 of 13 participants (23%) who received the placebo (P=.004). For women requiring oxytocin because of slow progression of labor, the corresponding results were 34 of 51 participants (66%) vs 16 of 40 participants (40%) (P=.004). In study 2, tafoxiparin had no positive effects on the secondary endpoints when compared with the placebo. Except for injection-site reactions in study 1, adverse events were no more common for tafoxiparin than for the placebo among either mothers or infants. There were few serious or treatment-related adverse events. CONCLUSION Subcutaneous treatment with tafoxiparin before labor onset (study 1) may be effective in reducing the labor time among women undergoing labor induction and among those requiring oxytocin for slow progression of labor. Moreover, tafoxiparin may have a positive effect on cervical ripening. Short-term, intravenous treatment with tafoxiparin as an adjunct to oxytocin in patients with labor arrest (study 2) did not affect labor time or other endpoints. Both studies suggest that tafoxiparin has a favorable safety profile in mothers and their infants.
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Affiliation(s)
- Gunvor Ekman-Ordeberg
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Dilafor AB, Solna, Sweden.
| | | | - Annika Jeppson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Leena Rahkonen
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland
| | - Marie Blomberg
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Karin Pettersson
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Carina Bejlum
- Department of Obstetrics and Gynecology, North Älvsborg County Hospital, Trollhättan, Sweden
| | - Malin Engberg
- Department of Obstetrics and Gynecology, Skaraborg Hospital, Skövde, Sweden
| | - Mette Ludvigsen
- Department of Obstetrics and Gynecology, Hvidovre Hospital, Hvidovre, Denmark
| | - Jukka Uotila
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Gunilla Hallberg
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Maria Jonsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Kekki M, Koukkula T, Salonen A, Gissler M, Laivuori H, Huttunen TT, Tihtonen K. Birth injury in breech delivery: a nationwide population-based cohort study in Finland. Arch Gynecol Obstet 2023; 308:1139-1150. [PMID: 36074174 PMCID: PMC10435420 DOI: 10.1007/s00404-022-06772-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/25/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Previous studies have examined the optimal mode of breech delivery extensively, but there is a scarcity of publications focusing on the birth injuries of neonates born in breech presentation. This study aimed to examine birth injury in breech deliveries. METHODS In this retrospective register-based nationwide cohort study, data on birth injuries in vaginal breech deliveries with singleton live births were compared to cesarean section with breech presentation and cephalic vaginal delivery between 2004 and 2017 in Finland. The data were retrieved from the National Medical Birth Register. Primary outcome variables were severe and mild birth injury. Incidences of birth injuries in different gestational ages and birthweights were calculated in different modes of delivery. Crude odds ratios of risk factors for severe birth injury were analyzed. RESULTS In vaginal breech delivery (n = 4344), there were 0.8% of neonates with severe birth injury and 1.5% of neonates with mild birth injury compared to 0.06% and 0.2% in breech cesarean section (n = 16,979) and 0.3% and 1.9% in cephalic vaginal delivery (n = 629,182). Brachial plexus palsy was the most common type of injury in vaginal breech delivery. Increasing gestational age and birthweight had a stronger effect on the risk for injury among cephalic vaginal deliveries than among vaginal breech deliveries. CONCLUSION Birth injuries were rare in vaginal breech deliveries. The incidence of severe birth injury was two times higher in vaginal breech delivery compared to cephalic vaginal delivery. Brachial plexus palsy was the most common type of injury in vaginal breech delivery.
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Affiliation(s)
- Maiju Kekki
- Department of Obstetrics and Gynecology, Tampere University Hospital, Elämänaukio 2, 33520, Tampere, Finland.
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - Topias Koukkula
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Anne Salonen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Pediatric and Adolescent Surgery, Tampere University Hospital, Tampere, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institute and Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden
| | - Hannele Laivuori
- Department of Obstetrics and Gynecology, Tampere University Hospital, Elämänaukio 2, 33520, Tampere, Finland
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Tuomas T Huttunen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Tampere University Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Elämänaukio 2, 33520, Tampere, Finland
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Kekki M, Salonen A, Koukkula T, Laivuori H, Tihtonen K, Huttunen TT. Incidence changes in risk factors associated with the decreasing number of birth-related clavicle fractures in Finland: A nationwide retrospective birth cohort from 2004 to 2017. Birth 2022; 50:428-437. [PMID: 35735132 DOI: 10.1111/birt.12662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/02/2022] [Accepted: 06/03/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND A clavicle fracture is one of the most common birth injuries. The objective of this study was to examine whether the decreased incidence of birth-related clavicle fractures in Finland is because of temporal changes in their predisposing factors. METHODS For this nationwide population-based study, we used the Finnish Medical Birth Register and the Care Register for Health Care databases. The study population included all singleton, live-born newborn born spontaneously or by vacuum-assisted delivery, in cephalic presentation ≥37+0 weeks of gestation. The incidences of clavicle fractures, pregnancy characteristics, and risk assessments for fracture were calculated and compared between two time periods: 2004-2010 and 2011-2017. RESULTS A total of 629 457 newborn were born vaginally between 2004 and 2017. The clavicle fracture incidence decreased from 17.6/1000 to 6.2/1000 live births. Shoulder dystocia, diabetes, and birthweight ≥4000 g were the strongest predisposing factors. The incidence of birthweight ≥4000 g decreased, meanwhile type 1 diabetes and shoulder dystocia remained stable and gestational diabetes, type 2 diabetes, and maternal obesity increased in the later study period. The incidence of clavicle fractures without known predisposing factors declined. Simultaneously, the cesarean birth rate remained stable (13.2%-13.1%), although the rate of vacuum-assisted deliveries increased (8.5%-9.5%). DISCUSSION The incidence of clavicle fractures decreased, even though the incidence of most risk factors remained stable or increased, and the cesarean birth rate remained stable. This decline may be related to the reduction of fracture incidence among deliveries without known risk factors, and the decrease in birthweight ≥4000 g.
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Affiliation(s)
- Maiju Kekki
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland.,Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Anne Salonen
- Department of Pediatric and Adolescent Surgery, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Topias Koukkula
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Hannele Laivuori
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland.,Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland.,Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Tuomas T Huttunen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Tampere University Heart Hospital, Tampere University Hospital, Tampere, Finland
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Korhonen P, Tihtonen K, Isojärvi J, Ojala R, Ashorn U, Ashorn P, Tammela O. Calcium supplementation during pregnancy and long‐term offspring outcome: a systematic literature review and meta‐analysis. Ann N Y Acad Sci 2022; 1510:36-51. [PMID: 34978718 PMCID: PMC9304138 DOI: 10.1111/nyas.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/04/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022]
Abstract
The World Health Organization currently recommends calcium supplementation for pregnant women, especially those with low calcium intakes, to reduce the risk of hypertension and preeclampsia. We aimed to evaluate the effect of this intervention on selected offspring outcomes. A systematic search was conducted in 11 databases for published randomized controlled trials (RCTs) on the effect of maternal calcium supplementation with or without vitamin D during pregnancy on selected offspring cardiovascular, growth, and metabolic and neurodevelopmental outcomes. Screening of titles and abstracts of 3555 records and full texts of 31 records yielded six RCTs (nine reports, n = 1616). Forest plot analyses were performed if at least two studies presented comparable data on the same outcome. In one study (n = 591), high‐dose calcium supplementation during pregnancy was associated with a decreased risk of offspring high systolic blood pressure at 5–7 years of age (risk ratio = 0.59; 95% confidence interval: 0.39–0.90). The effects of the intervention on offspring growth, metabolic, and neurodevelopmental outcomes remain unknown because of conflicting or insufficient data. High risk of attrition bias decreased the quality of the evidence. Limited available data from RCTs do not provide sufficient evidence to conclude that prenatal calcium supplementation influences offspring health outcomes beyond the newborn period.
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Affiliation(s)
- Päivi Korhonen
- Department of Pediatrics Tampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research Tampere University Tampere Finland
| | - Kati Tihtonen
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research Tampere University Tampere Finland
- Department of Obstetrics and Gynecology Tampere University Hospital Tampere Finland
| | | | - Riitta Ojala
- Department of Pediatrics Tampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research Tampere University Tampere Finland
| | - Ulla Ashorn
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research Tampere University Tampere Finland
| | - Per Ashorn
- Department of Pediatrics Tampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research Tampere University Tampere Finland
| | - Outi Tammela
- Department of Pediatrics Tampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research Tampere University Tampere Finland
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6
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Hoppu S, Hannola K, Mennander S, Huhtala H, Rissanen M, Tulensalo E, Laivuori H, Tihtonen K. Routine Bedside Use of Obstetric Early Warning System in the Postnatal Ward to Identify Maternal Morbidity Among High-Risk Women. J Patient Saf 2022; 18:e338-e342. [PMID: 32925568 DOI: 10.1097/pts.0000000000000766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Several authorities have recommended the use of an obstetric early warning system (OEWS) to prevent severe morbidity and mortality. Data on the accuracy of OEWS in different clinical settings and maternal populations are still scarce. Our aim was to validate OEWS to detect maternal morbidity among high-risk women in the postnatal ward. METHODS An OEWS was assigned to women with a body mass index >35 kg/m2, postpartum hemorrhage (PPH) >1500 mL, preeclampsia, concern over the maternal condition, chorioamnionitis, or type 1 diabetes. Morbidity was defined as worsening preeclampsia, action on hemorrhage, thromboembolia, diabetic ketoacidosis, puerperal infections, transfer to the intensive care unit, cardiopulmonary dysfunction, or death during the stay in the postnatal ward. The use of OEWS was implemented on November 1, 2016, and the study period ended on April 30, 2018. RESULTS The study group included 827 women. The incidence of maternal morbidity was 29%. Women with PPH (odds ratio [OR], 6.4 [95% confidence interval, 3.5-11.6]) and preeclampsia (OR, 5.7 [3.5-9.6]) had the highest risk for morbidity. The sensitivity of OEWS for any morbidity was 42% (35%-48%), the specificity was 83% (80%-86%), the positive predictive value was 50% (44%-56%), and the negative predictive value was 78% (76%-80%). Systolic (OR, 6.8 [4.0-11.5]) and diastolic (OR, 3.3 [1.8-6.0]) blood pressure as well as pulse (OR, 2.1 [1.1-4.2]) predicted morbidity the most. CONCLUSIONS In high-risk women, OEWS revealed one-half of the morbidity. Women with PPH and preeclampsia benefited most from it. Abnormal blood pressure and pulse had the strongest associations with morbidity.
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Affiliation(s)
| | - Katja Hannola
- Department of Obstetrics and Gynecology, Tampere University Hospital
| | - Susanna Mennander
- From the Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital
| | - Heini Huhtala
- Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere
| | - Maria Rissanen
- Faculty of Medicine and Health Technology, Tampere University
| | | | | | - Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital
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Kekki M, Tihtonen K, Salonen A, Koukkula T, Gissler M, Laivuori H, Huttunen TT. Severe birth injuries in neonates and associated risk factors for injury in mothers with different types of diabetes in Finland. Int J Gynaecol Obstet 2021; 159:195-203. [PMID: 34927725 PMCID: PMC9545198 DOI: 10.1002/ijgo.14073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 12/03/2021] [Accepted: 12/17/2021] [Indexed: 11/20/2022]
Abstract
Objective To examine severe birth‐related injuries in neonates among mothers with different types of diabetes. Methods Retrospective cohort study based on Finnish Medical Birth Register data from 2004 to 2017. The study included singleton neonates born vaginally with cephalic presentation (n = 623 649) after 35+0 weeks of gestation. The primary outcome variable was severe birth injury. Incidences, crude and adjusted odds ratios, and probabilities in regression analysis were calculated for different types of diabetes. Results There were 1952/623 649 (0.3%) severe birth injuries of which brachial plexus injury occurred most frequently. The injury incidence was highest in neonates of women with type 1 or type 2 diabetes, 42/1659 (2.5%) and 10/548 (1.8%), respectively. For gestational diabetes, the injury incidence was comparable to non‐diabetic women: 422/77 810 (0.5%) and 1478/543 632 (0.3%), respectively. Shoulder dystocia, high birthweight, and vacuum‐assisted delivery were associated with the highest probability for injury. Birthweight and obesity had a stronger impact on injury risk in women with pregestational diabetes compared to other pregnancies. Conclusion Neonates of women with pregestational diabetes have a higher risk for severe birth injury than other neonates. The injury risk in neonates delivered by women with gestational diabetes or non‐diabetic women is generally low.
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Affiliation(s)
- Maiju Kekki
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland.,Tampere University, Faculty of Medicine and Health Technology, Center for Child, Adolescent and Maternal Health Research, Tampere, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland.,Tampere University, Faculty of Medicine and Health Technology, Center for Child, Adolescent and Maternal Health Research, Tampere, Finland
| | - Anne Salonen
- Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland.,Department of Pediatric and Adolescent Surgery, Tampere University Hospital, Tampere, Finland
| | - Topias Koukkula
- Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland.,Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Mika Gissler
- Information Services Department, THL, Finnish Institute for Health and Welfare, Helsinki, Finland.,Department of Molecular Medicine and Surgery, Karolinska Institute and Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden
| | - Hannele Laivuori
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland.,Tampere University, Faculty of Medicine and Health Technology, Center for Child, Adolescent and Maternal Health Research, Tampere, Finland.,Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Tuomas T Huttunen
- Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland.,Tampere University Heart Hospital, Tampere University Hospital, Tampere, Finland
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8
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Tihtonen K, Korhonen P, Isojärvi J, Ojala R, Ashorn U, Ashorn P, Tammela O. Calcium supplementation during pregnancy and maternal and offspring bone health: a systematic review and meta-analysis. Ann N Y Acad Sci 2021; 1509:23-36. [PMID: 34780069 PMCID: PMC9298950 DOI: 10.1111/nyas.14705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/26/2021] [Indexed: 11/29/2022]
Abstract
Insufficient calcium intake during pregnancy may lead to maternal bone resorption and lower bone density of offspring. We evaluated the impact of supplementary calcium with or without vitamin D during pregnancy on maternal and offspring bone mineral density (BMD) and teeth firmness of the offspring. Randomized controlled trials (RCTs) were searched systematically in 11 databases. Two researchers independently screened the titles and abstracts of 3555 records and the full texts of 31 records to examine eligibility. The search yielded seven RCTs (11 reports, n = 1566). No advantage of calcium supplementation was found on maternal BMD after delivery or during breastfeeding, or on offspring BMD, even when dietary calcium intake was low. The results were neither modified by the dose of calcium nor concomitant vitamin D administration. A suspicion of some long‐term harm of the intervention on maternal BMD and growth of female offspring was raised based on the data. One study suggested some benefit of high‐dose calcium supplementation on offspring teeth firmness at 12 years old. A low number of the studies and abundant missing data reduced the quality of the findings. The impact of calcium supplementation on maternal and offspring bone health was deemed unknown because of inconclusive research results.
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Affiliation(s)
- Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research, Tampere University, Tampere, Finland
| | - Päivi Korhonen
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research, Tampere University, Tampere, Finland.,Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | | | - Riitta Ojala
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research, Tampere University, Tampere, Finland.,Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research, Tampere University, Tampere, Finland
| | - Per Ashorn
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research, Tampere University, Tampere, Finland.,Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Outi Tammela
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research, Tampere University, Tampere, Finland.,Department of Pediatrics, Tampere University Hospital, Tampere, Finland
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9
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Jernman R, Isaksson C, Haimila K, Kuosmanen M, Mäkikallio-Anttila K, Toivonen S, Ordén MR, Sulin K, Tihtonen K, Vääräsmäki M, Sainio S. Time points and risk factors for RhD immunizations after the implementation of targeted routine antenatal anti-D prophylaxis: A retrospective nationwide cohort study. Acta Obstet Gynecol Scand 2021; 100:1868-1875. [PMID: 34157128 DOI: 10.1111/aogs.14216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/16/2021] [Accepted: 06/18/2021] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Targeted routine antenatal anti-D prophylaxis was introduced to the national prophylaxis program in Finland in late 2013. The aim of this study was to assess the incidence, time-points, and risk factors for Rhesus D immunization after the implementation of routine antenatal anti-D prophylaxis, in all women in Finland with antenatal anti-D antibodies detected in 2014-2017. MATERIAL AND METHODS In a nationwide population-based retrospective cohort study, the incidence, time-points, and risk factors of anti-D immunizations were analyzed. Information on antenatal screening was obtained from the Finnish Red Cross Blood Service database, and obstetric data from hospital records and the Finnish Medical Birth Register. RESULTS The study included a total of 228 women (197 with complete data for all pregnancies). After the implementation of routine antenatal anti-D prophylaxis, the prevalence of pregnancies with anti-D antibodies decreased from 1.52% in 2014 to 0.88% in 2017, and the corresponding incidence of new immunizations decreased from 0.33% to 0.10%. Time-points for detection of new anti-D antibodies before and after 2014 were the first screening sample at 8-12 weeks of gestation in 52% versus 19%, the second sample at 24-26 weeks in 20% versus 50%, and the third screening at 36 weeks in 28% versus 32%. CONCLUSIONS The incidence of new anti-D immunizations decreased as expected after the implementation of routine antenatal anti-D prophylaxis. True failures are rare and they mainly occur when the prophylaxis is not given appropriately, suggesting a need for constant education of healthcare professionals on the subject.
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Affiliation(s)
- Riina Jernman
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Camilla Isaksson
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | | | | | - Maija-Riitta Ordén
- Department of Obstetrics and Gynecology, Kuopio University Hospital, Kuopio, Finland
| | - Kati Sulin
- Finnish Red Cross Blood Service, Helsinki, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Marja Vääräsmäki
- Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland
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10
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Hannola K, Hoppu S, Mennander S, Huhtala H, Laivuori H, Tihtonen K. Obstetric early warning system to predict maternal morbidity of pre-eclampsia, postpartum hemorrhage and infection after birth in high-risk women: a prospective cohort study. Midwifery 2021; 99:103015. [PMID: 33915316 DOI: 10.1016/j.midw.2021.103015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 03/24/2021] [Accepted: 04/08/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The purpose of early warning systems is to detect deterioration of the patient and to enable timely intervention to prevent possible severe illness. The most common causes of maternal morbidity and mortality after birth are worsening pre-eclampsia, postpartum haemorrhage and puerperal infection. Our aim was to validate the accuracy of the obstetric early warning system and different physiological triggers to predict morbidity on the postnatal ward in high-risk women. DESIGN A prospective cohort study. SETTING A tertiary referral hospital in Finland. PARTICIPANTS High-risk women (n=828) (body mass index > 35 kg/m2, postpartum haemorrhage > 1,500 g, pre-eclampsia, chorioamnionitis during birth, type 1 diabetes or anxiety over the maternal condition based on clinical judgement) were studied on the postnatal ward in the first 24 hours after giving birth. In this study population the women without any morbidity served as a control group. The study was conducted between 1.11.2016 - 30.4. 2018 covering a period of 18 months. MEASUREMENTS AND FINDINGS The accuracy of the obstetric early warning system and its five physiological parameters-respiratory rate, oxygen saturation, blood pressure, heart rate and body temperature-and a pain score to predict worsening pre-eclampsia, complications related to postpartum haemorrhage and puerperal infection were determined. A red trigger is as a single, markedly abnormal observation, and a yellow trigger is a combination of two mildly abnormal observations. The sensitivity of obstetric early warning system at its best was 72% for pre-eclampsia, 52% for infection and 25% for postpartum haemorrhage. The red triggers were significantly associated with morbidity in each outcome studied. The red triggers of systolic blood pressure (OR 25.7, 95% CI 13.2-50.1) and diastolic blood pressure (OR 22.1, 95% CI 11.3-43.0) were independently associated with pre-eclampsia, systolic blood pressure (OR 2.7, 95% CI 1.4-5.6) and heart rate (OR 3.6, 95% CI 1.7-7.6) with postpartum haemorrhage and heart rate (OR 3.3, 1.0-10.3) with infection. KEYCONCLUSIONS The sensitivity of obstetric early warning system varied depending on the type of morbidity. The highest sensitivity and positive predictive value were in pre-eclampsia. Systolic and diastolic blood pressure and heart rate were the strongest physiological parameters to predict morbidity. IMPLICATIONS FOR PRACTICE The systematic use of obstetric early warning system helps to improve maternal safety after birth in high-risk women. Blood pressure and pulse are the most important measurements.
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Affiliation(s)
- Katja Hannola
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere Finland
| | - Sanna Hoppu
- Department of Emergency, Anesthesia and Pain Medicine, Tampere University Hospital, Tampere, Finland
| | - Susanna Mennander
- Department of Emergency, Anesthesia and Pain Medicine, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Hannele Laivuori
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere Finland; Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland; Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere Finland.
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11
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Virtanen A, Huttala O, Tihtonen K, Toimela T, Heinonen T, Laivuori H, Uotila J. Angiogenic Effect of Pravastatin Alone and with Sera from Healthy and Complicated Pregnancies Studied by in vitro Vasculogenesis/Angiogenesis Assay. J Vasc Res 2021; 58:139-147. [PMID: 33571991 DOI: 10.1159/000512831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 11/02/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine the direct effect of pravastatin on angiogenesis and to study the interaction between pravastatin and maternal sera from women with early- or late-onset pre-eclampsia (PE), intrauterine growth restriction, or healthy pregnancy. METHODS We collected 5 maternal serum samples from each group. The effect of pravastatin on angiogenesis was assessed with and without maternal sera by quantifying tubule formation in a human-based in vitro assay. Pravastatin was added at 20, 1,000, and 8,000 ng/mL concentrations. Concentrations of angiogenic and inflammatory biomarkers in serum and in test medium after supplementation of serum alone and with pravastatin (1,000 ng/mL) were measured. RESULTS Therapeutic concentration of pravastatin (20 ng/mL) did not have significant direct effect on angiogenesis, but the highest concentrations inhibited angiogenesis. Pravastatin did not change the levels of biomarkers in the test media. There were no changes in angiogenesis when therapeutic dose of pravastatin was added with maternal sera, but there was a trend to wide individual variation towards enhanced angiogenesis, particularly in the early-onset PE group. CONCLUSIONS At therapeutic concentration, pravastatin alone or with maternal sera has no significant effect on angiogenesis, but at high concentrations the effect seems to be anti-angiogenic estimated by in vitro assay.
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Affiliation(s)
- Anita Virtanen
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland,
| | - Outi Huttala
- FICAM, Finnish Centre for Alternative Methods, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland
| | - Tarja Toimela
- FICAM, Finnish Centre for Alternative Methods, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Tuula Heinonen
- FICAM, Finnish Centre for Alternative Methods, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Hannele Laivuori
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jukka Uotila
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland
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12
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Kekki M, Salonen A, Tihtonen K, Mattila VM, Gissler M, Huttunen TT. The incidence of birth injuries decreased in Finland between 1997 and 2017: A nationwide register study. Acta Paediatr 2020; 109:2562-2569. [PMID: 32201987 DOI: 10.1111/apa.15267] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/02/2020] [Accepted: 03/18/2020] [Indexed: 12/16/2022]
Abstract
AIM Birth injuries are rare complications that can have a significant impact on neonates and their families. This population-based study describes the rates and trends of all birth injuries in Finland over a 21-year period. METHODS The study is based on a national Medical Birth Register that includes all live-born neonates of more than 22 gestational weeks or 500 g who were born in Finland between 1997 and 2017. The ICD-10 codes of the birth injuries were obtained from the Finnish Medical Birth Register and the Care Register for Health Care. The incidence of birth injury, changes over time and incidence at different gestational ages were determined. RESULTS A total of 28 551 birth injuries were diagnosed, and the total incidence decreased from 34.0 to 16.6 per 1000 live births. The incidence of clavicle fracture, cephalohaematoma, and Erb paralysis decreased while the incidence of chignon and epicranial subaponeurotic haemorrhage increased. CONCLUSION The incidence of birth injury halved during the 20-year study period. This was mainly due to a decrease in the number of clavicle fractures. The incidence of birth injury increased with gestational age, and most injuries occurred after 37 weeks of gestation.
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Affiliation(s)
- Maiju Kekki
- Department of Obstetrics and Gynecology Tampere University Hospital Tampere Finland
| | - Anne Salonen
- Department of Pediatric and Adolescent Surgery Tampere University Hospital Tampere Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynecology Tampere University Hospital Tampere Finland
| | - Ville M. Mattila
- Department of Orthopedics and Traumatology Department of Trauma, Musculoskeletal Surgery and Rehabilitation Tampere University Hospital Tampere Finland
| | - Mika Gissler
- Finnish Institute for Health and Welfare Helsinki Finland
- Department of Neurobiology, Care Sciences and Society Karolinska Institute Stockholm Sweden
| | - Tuomas T. Huttunen
- Department of Emergency, Anesthesia and Pain Medicine Tampere University Hospital Tampere Finland
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13
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Ovaskainen K, Ojala R, Tihtonen K, Gissler M, Luukkaala T, Tammela O. Unplanned out-of-hospital deliveries in Finland: A national register study on incidence, characteristics and maternal and infant outcomes. Acta Obstet Gynecol Scand 2020; 99:1691-1699. [PMID: 32609879 DOI: 10.1111/aogs.13947] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/17/2020] [Accepted: 06/20/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Unplanned out-of-hospital deliveries (UOHDs) have earlier been related to higher perinatal mortality and morbidity, but recent research has not paid much attention to them. Our aim was to evaluate the incidence, characteristics, risk factors, and maternal and perinatal mortality and morbidity in UOHDs in Finland. MATERIAL AND METHODS We conducted a national register study on births, causes of death and congenital anomalies for all live and stillbirths during 1996-2013. The study group included 1420 infants delivered by mothers with UOHDs. The 1 051 139 infants born in hospitals during the study period were the reference group. Data on maternal and delivery characteristics, obstetric procedures, infants' characteristics, neonatal care unit admissions, diagnoses, congenital anomalies and causes of death were collected. RESULTS The annual rate of UOHDs increased in 1996-2013 from 46 to 260 per 100 000 deliveries, whereas the number of delivery units decreased from 44 to 29. UOHD infants had five times higher perinatal mortality rates than those delivered in hospitals. The perinatal mortality rate did not change by time in the UOHDs, whereas it diminished among in-hospital deliveries. Maternal morbidity in UOHDs was low. The predictors for UOHDs were delivery after the year 2001, delivery in sparsely populated areas, alcohol, drug abuse and/or smoking during pregnancy, being single, fewer prenatal visits, having delivered earlier and birthweight <2500 g. UOHD was one of the predictors of perinatal morbidity and mortality. Among the UOHD cases, the predictors of perinatal morbidity or mortality included low birthweight and preterm delivery. Time period seemed not to predict morbidity or mortality. CONCLUSIONS The UOHD rate increased, probably due to multifactorial causes, including living in area with low population density and short duration of labor. UOHD was a significant predictor of perinatal morbidity or mortality, but the numbers were very small. Neonatal morbidity and mortality in UOHDs did not seem to be related to the area or time period of birth.
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Affiliation(s)
- Katja Ovaskainen
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland.,School of Medicine Doctoral Program, University of Tampere, Tampere, Finland
| | - Riitta Ojala
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Mika Gissler
- Finnish Institute for Health and Welfare, Helsinki, Finland.,Karolinska Institutet, Stockholm, Sweden
| | - Tiina Luukkaala
- Research, Development and Innovation Center, Tampere University Hospital, Tampere, Finland.,Faculty of Social Sciences, Health Sciences, Tampere University, Tampere, Finland
| | - Outi Tammela
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland
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14
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Virtanen A, Huttala O, Tihtonen K, Toimela T, Heinonen T, Laivuori H, Uotila J. Therapeutic doses of metformin do not have impact on angiogenesis in presence of sera from pre-eclamptic, IUGR and healthy pregnancies. Pregnancy Hypertens 2020; 22:7-13. [PMID: 32682321 DOI: 10.1016/j.preghy.2020.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 01/15/2023]
Abstract
Recent evidence suggests that metformin may prevent pre-eclampsia by reverting the angiogenic imbalance in maternal sera. In this study, we investigated effect of metformin on angiogenesis by quantifying tubule formation in a human-based in vitro test with co-culture of human adipose stromal cell (hASC) and human umbilical vein endothelial cell (HUVEC). A total of 20 pregnant women were recruited in the study. Serum samples were obtained from women with early- and late-onset pre-eclampsia and from women with pregnancies complicated by intrauterine growth restriction (IUGR) without pre-eclampsia (N = 5 in each of the three groups). Serum samples from women with healthy pregnancies served as controls (N = 5). The direct effect of metformin on angiogenesis was first assessed without maternal sera. Secondly, we investigated the impact of metformin on angiogenesis in the present of maternal sera. Metformin was used at 5, 50 and 600 µg/ml concentrations. Angiogenic and inflammatory biomarkers in maternal sera were analyzed by immunoassays. When the direct effect of metformin was studied, the two lowest concentrations of metformin did not affect tubule formation (angiogenesis), but the highest concentration inhibited angiogenesis. When metformin was supplemented at therapeutic concentrations of 5 and 50 µg/ml along with serum samples, there was no change in tubule formation in comparison to maternal sera alone. However, strong inhibitory effect on tubule formation was observed in all groups with the highest, non-therapeutic (600 µg/ml), concentration of metformin.
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Affiliation(s)
- Anita Virtanen
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland.
| | - Outi Huttala
- FICAM, Finnish Centre for Alternative Methods, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland
| | - Tarja Toimela
- FICAM, Finnish Centre for Alternative Methods, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Tuula Heinonen
- FICAM, Finnish Centre for Alternative Methods, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Hannele Laivuori
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jukka Uotila
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland
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15
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Hokkila E, Kruit H, Rahkonen L, Timonen S, Mattila M, Laatio L, Ordén MR, Uotila J, Luukkaala T, Tihtonen K. The efficacy of misoprostol vaginal insert compared with oral misoprostol in the induction of labor of nulliparous women: A randomized national multicenter trial. Acta Obstet Gynecol Scand 2019; 98:1032-1039. [PMID: 30771243 DOI: 10.1111/aogs.13580] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/09/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Our objective was to compare the efficacy of a 200-μg misoprostol vaginal insert vs oral misoprostol regarding the cesarean section rate and the time interval to vaginal delivery in nulliparous women with unfavorable cervix. MATERIAL AND METHODS In this prospective multicenter trial, 283 nulliparous women at term with Bishop score <6 were randomized to induction of labor with either a misoprostol vaginal insert (n = 140) or oral misoprostol (n = 143). In the oral misoprostol group, a 50-μg dose of oral misoprostol was administered every 4 hours up to three times during the first day; during the second day, the dose was increased to 100-μg every 4 hours up to three times during the first day, if necessary. Primary outcome was the cesarean section rate. Secondary outcomes were the time from induction of labor to vaginal delivery, the rate of other induction methods needed, labor augmentation with oxytocin and/or amniotomy, use of tocolytics and adverse neonatal and maternal events. RESULTS In the misoprostol vaginal insert group, median time to vaginal delivery was shorter (24.5 hours vs 44.2 hours, P < 0.001), whereas no difference was found in the cesarean section rate (33.8% vs 29.6%, odds ratio [OR] 1.21, 95% confidence interval [CI] 0.66-1.91, P = 0.67). Other induction methods and labor augmentation with oxytocin and/or amniotomy were less frequent in the misoprostol vaginal insert group (OR 0.32, 95% CI 0.18-0.59 and OR 0.56, 95% CI 0.32-0.99, respectively). Need for tocolysis and meconium-stained amniotic fluid were more common in the misoprostol vaginal insert group (OR 3.63, 95% CI 1.12-11.79 and OR 2.38, 95% CI 1.32-4.29, respectively). Maternal and neonatal adverse events did not differ between groups. CONCLUSIONS Misoprostol vaginal insert proved to shorten the time to vaginal delivery and to reduce the use of other methods of labor induction and augmentation, but it did not reduce the cesarean section rate compared with oral misoprostol. The benefit of more rapid delivery associated with misoprostol vaginal insert should be weighed against the greater risks for uterine hyperstimulation and meconium-stained amniotic fluid.
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Affiliation(s)
- Emma Hokkila
- Department of Obstetrics and Gynecology, Lapland Central Hospital, Rovaniemi, Finland
| | - Heidi Kruit
- Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland.,Helsinki University, Helsinki, Finland
| | - Leena Rahkonen
- Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland.,Helsinki University, Helsinki, Finland
| | - Susanna Timonen
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland
| | - Mirjami Mattila
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland
| | - Liisa Laatio
- Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland
| | - Maija-Riitta Ordén
- Department of Obstetrics and Gynecology, Kuopio University Hospital, Kuopio, Finland
| | - Jukka Uotila
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Tiina Luukkaala
- Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland.,Research, Development and Innovation Center, Tampere University Hospital, Tampere, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
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16
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Kruit H, Tihtonen K, Raudaskoski T, Ulander VM, Aitokallio-Tallberg A, Heikinheimo O, Paavonen J, Rahkonen L. Foley Catheter or Oral Misoprostol for Induction of Labor in Women with Term Premature Rupture of Membranes: A Randomized Multicenter Trial. Am J Perinatol 2016; 33:866-72. [PMID: 27031055 DOI: 10.1055/s-0036-1580608] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objectives To compare the Foley catheter and misoprostol for induction of labor in term women with premature rupture of membranes. Study Design A randomized controlled trial was performed in three university hospitals in Finland between March 2012 and September 2014. A total of 202 term women with ruptured membranes >18 hours, singleton pregnancies in cephalic presentation, unfavorable cervix, and no prior cesarean section were enrolled. Participants were randomly allocated to induction of labor by Foley catheter or oral misoprostol in a 1:1 ratio. All women received prophylactic antibiotics. The main outcomes were cesarean section and maternal and neonatal infections. Results Labor induction by Foley catheter or misoprostol showed no difference in cesarean delivery rates (23.6 vs. 18.2%; odds ratio [OR], 1.39; 95% confidence interval [CI], 0.69-2.82; p = 0.36), maternal intrapartum infections (2.2 vs. 2%; OR, 1.12; 95% CI, 0.15-8.9; p = 1.00), postpartum infections (1.1 vs. 2.0%; OR, 0.55; 95% CI, 0.05-6.18; p = 1.00), or neonatal infections (1.1 vs. 5.1%; OR, 0.21; 95% CI, 0.24-1.87; p = 0.22). The total time from induction to delivery was similar (1,311 vs. 1,435 minutes; p = 0.31) in the two groups. Conclusions Foley catheter or misoprostol can both be used for induction of labor in women with term premature rupture of membranes.
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Affiliation(s)
- Heidi Kruit
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Tytti Raudaskoski
- Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland
| | - Veli-Matti Ulander
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ansa Aitokallio-Tallberg
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Oskari Heikinheimo
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jorma Paavonen
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Leena Rahkonen
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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17
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Tihtonen K, Nyberg R. [Long-term effects of uterine cesarean section scar]. Duodecim 2014; 130:461-468. [PMID: 24730196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
During the last few decades the cesarean delivery rate has been around 15% in Finland. It has remained moderate compared with USA where 30% of women deliver by cesarean section. Compared with vaginal delivery, cesarean section is associated with a three- to sixfold risk of severe complications. Furthermore, it increases also long term gynecological morbidity, including intermenstrual bleeding, chronic pelvic pain and risk of secondary infertility. Scar pregnancy, uterine rupture, placenta previa and accrete are known risks after cesarean section. Because cesarean delivery is associated with increased long-term morbidity, the decision of performing cesarean section should always be carefully considered.
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18
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Tihtonen K, Uotila J, Lähde J, Salo M, Keskinen P. Risk of hyperammonemic coma in the puerperium: two cases of women with diagnosed and undiagnosed deficiency of urea cycle enzymes. Acta Obstet Gynecol Scand 2010; 89:404-6. [DOI: 10.3109/00016340903540646] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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19
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Aukee P, Tihtonen K. [Pregnancy, delivery and pelvic floor disorders]. Duodecim 2010; 126:2381-2386. [PMID: 21125752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Pregnancy and vaginal delivery affect pelvic floor by increased intra-abdominal pressure, direct muscle trauma, nerve injury and connective tissue damage. Even if pelvic floor dysfunction is more common after vaginal delivery compared to cesarean section, the differences are less clear after long-term follow up. This implies that other factors such as age, estrogen levels, genetic factors and overweight have also a role in the pathophysiology of pelvic floor dysfunctions. It is possible to prevent some of the birth injuries by careful obstetric management. Pelvic floor muscle training during pregnancy or after delivery may reduce the incidence of fecal and urinary incontinence after delivery, but data about long-term effects is scarce.
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Affiliation(s)
- Pauliina Aukee
- Keski-Suomen keskussairaala, synnytysten ja naistentautien yksikkö sekä lantionpohjan tutkimus- ja hoitoyksikkö, Jyväskylä
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20
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Tihtonen K, Lagerstedt A, Kähkönen M, Kirkinen P. Diamniotic omphalopagus conjoined twins in a diamniotic pregnancy. Fetal Diagn Ther 2009; 25:343-5. [PMID: 19776599 DOI: 10.1159/000235882] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Accepted: 12/22/2008] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To present antepartal diagnostic findings including 2D/3D ultrasonography in a rare case of conjoined twins with diamniotic placentation. METHODS In ultrasonographic examination, a communicating structure containing solid and cystic components together with cord vessels was found between the fetuses. The long axes of the fetuses were not parallel and they moved independently. Bladder configurations were absent. A fetal membrane from the chorioidal plate was imaged. RESULTS Postmortem pathological examination revealed that the twins were conjoined by way of fused cloacal exstrophy and omphalocele, and the separate amniotic cavities communicated via a fused allantoic cavity. The placenta was monochorionic and diamniotic. DNA analysis of the twins and the placenta confirmed the monozygotic origin. CONCLUSION Visualization of the amniotic membrane does not rule out conjoined twins in rare cases of monochorionic twin pregnancies.
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Affiliation(s)
- K Tihtonen
- Departments of Obstetrics and Gynecology, Tampere University Hospital, PL 2000, Tampere FI-33521, Finland.
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Abstract
OBJECTIVE To assess hemodynamic and NT-proANP changes in women with chronic hypertension during pregnancy. METHODS Stroke volume index (SI), heart rate (HR), cardiac output index (CI), systemic vascular resistance index (SVRI), pulse wave velocity (PWV), and left cardiac work index (LCWI) were measured using whole-body impedance cardiography. Systolic blood pressure (SAP), mean arterial pressure (MAP), diastolic blood pressure (DAP), and pulse pressure (PP) were also measured. Arterial compliance was defined as the SI-to-PP ratio (SI/PP). Hemodynamic parameters and NT-proANP concentrations were assessed during the early and late second trimester, the third trimester, and after delivery in 20 women with essential hypertension and 30 normotensive women. RESULTS Arterial blood pressure, SVRI, and PWV remained higher during the whole study period in chronic hypertensive compared with healthy pregnancies. In the early second trimester, women with chronic hypertension had significantly lower SI and NT-proANP concentrations than did normotensive women. CONCLUSION The hemodynamics of chronic hypertension during pregnancy are characterized by persistent high vascular resistance. Lower SI and NT-proANP values found in chronic hypertensive pregnancies during the early second trimester may suggest a reduced intravascular volume increase during pregnancy.
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Affiliation(s)
- Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland.
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Abstract
OBJECTIVE To determine how pre-eclampsia modifies maternal haemodynamics during caesarean delivery. DESIGN Prospective study. SETTING Tampere University Hospital, Finland. POPULATION Ten pre-eclamptic parturients and ten healthy parturients with uncomplicated pregnancies scheduled for elective caesarean section under spinal anaesthesia. METHODS Haemodynamic parameters were assessed by whole-body impedance cardiography noninvasively. MAIN OUTCOME MEASURES Stroke index (SI), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI) and mean arterial pressure (MAP) were recorded before operation, continuously during caesarean section, during the period of dissipation of anaesthesia and on the second to fifth postpartum day. RESULTS Baseline haemodynamics in women with pre-eclampsia differed significantly from healthy women in higher SVRI and MAP and lower SI and CI. In women with pre-eclampsia, preload infusion increased both SI and HR, causing a significant rise in CI, while in healthy parturients, only HR rose. In both the groups, spinal blockade reduced SVRI but CI remained stable. At the moment of delivery, CI increased in both groups. In uncomplicated pregnancies, both SI and HR increased, but in women with pre-eclampsia, SI was not altered and the rise in CI was due to an increase in HR only. After the reversal of anaesthesia, haemodynamics in the control group returned to baseline values, whereas in women with pre-eclampsia, SI and CI fell to levels that were significantly lower than the levels observed before surgery. CONCLUSIONS In women with pre-eclampsia, inability to increase SI at the moment of delivery may suggest dysfunction of the left ventricle to adapt to volume load caused by delivery and prompts concern for the increased risk of pulmonary oedema.
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Affiliation(s)
- K Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland.
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Abstract
BACKGROUND This descriptive study was designed to evaluate maternal hemodynamics and cardiovascular responses to delivery during cesarean section (CS) under spinal anesthesia. We also assessed the feasibility of a noninvasive and continuous method of measuring cardiac output, namely whole-body impedance cardiography (ICG(WB)), during elective CS. Because of the techniques used in previous studies, only fractionated data on maternal hemodynamics during CS are available to date. METHODS We studied 10 healthy women with normal pregnancies and two pregnant women with heart disease undergoing elective CS. Mean arterial pressure (MAP), heart rate (HR), stroke index (SI), cardiac index (CI) and systemic vascular resistance index (SVRI) were recorded continuously during CS, during the period of dissipation of anesthesia and on the second to fifth postpartum day. Analysis of variance for repeated measurements (anova) and the paired sample t-test were used in statistical analysis. RESULTS The hemodynamic parameters could be registered continuously during the whole procedure. At the point of delivery, a 47% increase in CI and a 39% decrease in SVRI were recorded, while MAP remained stable. These changes occurred within 2 min of delivery of the newborn and persisted on average for 10 min. CONCLUSION Sudden and significant hemodynamic changes take place at the moment of delivery. Intact physiological cardiovascular compensation mechanisms are needed to adapt to these challenges. Whole-body impedance cardiography may offer a useful noninvasive tool to monitor hemodynamics during cesarean section.
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Affiliation(s)
- Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland.
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