Postpartum pelvic organ prolapse and pelvic floor muscle training: secondary analysis of a randomized controlled trial of primiparous women

INTRODUCTION AND HYPOTHESIS

Pelvic floor dysfunction is common after childbirth. We hypothesize that physiotherapist-guided pelvic floor muscle training (PFMT) is effective regarding pelvic organ prolapse (POP) symptoms during the first postpartum year.

METHODS

This was a secondary analysis from a randomized controlled trial (RCT), carried out at a physiotherapy clinic, Reykjavik. Participants were eighty-four primiparous women with a singleton delivery. They were screened for eligibility 6-13 weeks postpartum. Women in a training group conducted 12 weekly individual sessions with a physiotherapist within an RCT, starting on average 9 weeks postpartum. Outcomes were assessed after the last session (short term) and at approximately 12 months postpartum (long term). The control group received no instructions after the initial assessment. Main outcome measures were self-evaluated POP symptoms by the Australian Pelvic Floor Questionnaire.

RESULTS

Forty-one and 43 women were in the training and control groups, respectively. At recruitment, 17 (42.5%) of the training group and 15 (37%) of the control group reported prolapse symptoms (p = 0.6). Five (13%) from the training group and nine (21%) controls were bothered by the symptoms (p = 0.3). There was a gradual decrease in the number of women with symptoms and no significant short-term (p = 0.08) or long-term (p = 0.6) differences between the groups regarding rates of women with POP symptoms. The difference between groups regarding bother in the short (p = 0.3) or longer term (p = 0.4) was not significant. Repeated-measures analyses using Proc Genmod in SAS did not indicate a significant effect of the intervention over time (p > 0.05).

CONCLUSIONS

There was an overall decrease in postpartum symptoms of POP and bother during the first year. Physiotherapist-led PFMT did not change the outcomes.

CLINICAL TRIAL REGISTRATION

The trial was registered 30 March 2015 at https://register.

CLINICALTRIALS

gov (NCT02682212). Initial participant enrollment was on 16 March 2016 and reported following CONSORT guidelines for randomized controlled trials.

The genetic basis of endometriosis and comorbidity with other pain and inflammatory conditions

Endometriosis is a common condition associated with debilitating pelvic pain and infertility. A genome-wide association study meta-analysis, including 60,674 cases and 701,926 controls of European and East Asian descent, identified 42 genome-wide significant loci comprising 49 distinct association signals. Effect sizes were largest for stage 3/4 disease, driven by ovarian endometriosis. Identified signals explained up to 5.01% of disease variance and regulated expression or methylation of genes in endometrium and blood, many of which were associated with pain perception/maintenance (SRP14/BMF, GDAP1, MLLT10, BSN and NGF). We observed significant genetic correlations between endometriosis and 11 pain conditions, including migraine, back and multisite chronic pain (MCP), as well as inflammatory conditions, including asthma and osteoarthritis. Multitrait genetic analyses identified substantial sharing of variants associated with endometriosis and MCP/migraine. Targeted investigations of genetically regulated mechanisms shared between endometriosis and other pain conditions are needed to aid the development of new treatments and facilitate early symptomatic intervention.

Can ultrasound on admission in active labor predict labor duration and a spontaneous delivery?

BACKGROUND

Identifying predictive factors for a normal outcome at admission in the labor ward would be of value for planning labor care, timing interventions, and preventing labor dystocia. Clinical assessments of fetal head station and position at the start of labor have some predictive value, but the value of ultrasound methods for this purpose has not been investigated. Studies using transperineal ultrasound before labor onset show possibilities of using these methods to predict outcomes.

OBJECTIVE

This study aimed to investigate whether ultrasound measurements during the first examination in the active phase of labor were associated with the duration of labor phases and the need for operative delivery.

STUDY DESIGN

This was a secondary analysis of a prospective cohort study at Landspitali University Hospital, Reykjavík, Iceland. Nulliparous women at ≥37 weeks' gestation with a single fetus in cephalic presentation and in active spontaneous labor were eligible for the study. The recruitment period was from January 2016 to April 2018. Women were examined by a midwife on admission and included in the study if they were in active labor, which was defined as regular contractions with a fully effaced cervix, dilatation of ≥4 cm. An ultrasound examination was performed by a separate examiner within 15 minutes; both examiners were blinded to the other's results. Transabdominal and transperineal ultrasound examinations were used to assess fetal head position, cervical dilatation, and fetal head station, expressed as head-perineum distance and angle of progression. Duration of labor was estimated as the hazard ratio for spontaneous delivery using Kaplan-Meier curves and Cox regression analysis. The hazard ratios were adjusted for maternal age and body mass index. The associations between study parameters and mode of delivery were evaluated using receiver operating characteristic curves.

RESULTS

Median times to spontaneous delivery were 490 minutes for a head-perineum distance of ≤45 mm and 682 minutes for a head-perineum distance of >45 mm (log-rank test, P=.009; adjusted hazard ratio for a shorter head-perineum distance, 1.47 [95% confidence interval, 0.83-2.60]). The median durations were 506 minutes for an angle of progression of ≥93° and 732 minutes for an angle of progression of <93° (log-rank test, P=.008; adjusted hazard ratio, 2.07 [95% confidence interval, 1.15-3.72]). The median times to delivery were 506 minutes for nonocciput posterior positions and 677 minutes for occiput posterior positions (log-rank test, P=.07; adjusted hazard ratio, 1.52 [95% confidence interval, 0.96-2.38]) Median times to delivery were 429 minutes for a dilatation of ≥6 cm and 704 minutes for a dilatation of 4 to 5 cm (log-rank test, P=.002; adjusted hazard ratio, 3.11 [95% confidence interval, 1.68-5.77]). Overall, there were 75 spontaneous deliveries; among those deliveries, 16 were instrumental vaginal deliveries (1 forceps delivery and 15 ventouse deliveries), and 8 were cesarean deliveries. Head-perineum distance and angle of progression were associated with a spontaneous delivery with area under the receiver operating characteristic curves of 0.68 (95% confidence interval, 0.55-0.80) and 0.67 (95% confidence interval, 0.55-0.80), respectively. Ultrasound measurement of cervical dilatation or position at inclusion was not significantly associated with spontaneous delivery.

CONCLUSION

Ultrasound examinations showed that fetal head station and cervical dilatation were associated with the duration of labor; however, measurements of fetal head station were the variables best associated with operative deliveries.

Fetal descent in nulliparous women assessed by ultrasound: a longitudinal study

BACKGROUND

Ultrasound measurements offer objective and reproducible methods to measure the fetal head station. Before these methods can be applied to assess labor progression, the fetal head descent needs to be evaluated longitudinally in well-defined populations and compared with the existing data derived from clinical examinations.

OBJECTIVE

This study aimed to use ultrasound measurements to describe the fetal head descent longitudinally as labor progressed through the active phase in nulliparous women with spontaneous onset of labor.

STUDY DESIGN

This was a single center, prospective cohort study at the Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland, from January 2016 to April 2018. Nulliparous women with a single fetus in cephalic presentation and spontaneous labor onset at a gestational age of ≥37 weeks, were eligible. Participant inclusion occurred during admission for women with an established active phase of labor or at the start of the active phase for women admitted during the latent phase. The active phase was defined as an effaced cervix dilated to at least 4 cm in women with regular contractions. According to the clinical protocol, vaginal examinations were done at entry and subsequently throughout labor, paired each time with a transperineal ultrasound examination by a separate examiner, with both examiners being blinded to the other's results. The measurements used to assess the fetal head station were the head-perineum distance and angle of progression. Cervical dilatation was examined clinically.

RESULTS

The study population comprised 99 women. The labor patterns for the head-perineum distance, angle of progression, and cervical dilatation differentiated the participants into 75 with spontaneous deliveries, 16 with instrumental vaginal deliveries, and 8 cesarean deliveries. At the inclusion stage, the cervix was dilated 4 cm in 26 of the women, 5 cm in 30 of the women, and ≥6 cm in 43 women. One cesarean and 1 ventouse delivery were performed for fetal distress, whereas the remaining cesarean deliveries were conducted because of a failure to progress. The total number of examinations conducted throughout the study was 345, with an average of 3.6 per woman. The ultrasound-measured fetal head station both at the first and last examination were associated with the delivery mode and remaining time of labor. In spontaneous deliveries, rapid head descent started around 4 hours before birth, the descent being more gradual in instrumental deliveries and absent in cesarean deliveries. A head-perineum distance of 30 mm and angle of progression of 125° separately predicted delivery within 3.0 hours (95% confidence interval, 2.5-3.8 hours and 2.4-3.7 hours, respectively) in women delivering vaginally. Although the head-perineum distance and angle of progression are independent methods, both methods gave similar mirror image patterns. The fetal head station at the first examination was highest for the fetuses in occiput posterior position, but the pattern of rapid descent was similar for all initial positions in spontaneously delivering women. Oxytocin augmentation was used in 41% of women; in these labors a slower descent was noted. Descent was only slightly slower in the 62% of women who received epidural analgesia. A nonlinear relationship was observed between the fetal head station and dilatation.

CONCLUSION

We have established the ultrasound-measured descent patterns for nulliparous women in spontaneous labor. The patterns resemble previously published patterns based on clinical vaginal examinations. The ultrasound-measured fetal head station was associated with the delivery mode and remaining time of labor.

Genetic predisposition to hypertension is associated with preeclampsia in European and Central Asian women

Preeclampsia is a serious complication of pregnancy, affecting both maternal and fetal health. In genome-wide association meta-analysis of European and Central Asian mothers, we identify sequence variants that associate with preeclampsia in the maternal genome at ZNF831/20q13 and FTO/16q12. These are previously established variants for blood pressure (BP) and the FTO variant has also been associated with body mass index (BMI). Further analysis of BP variants establishes that variants at MECOM/3q26, FGF5/4q21 and SH2B3/12q24 also associate with preeclampsia through the maternal genome. We further show that a polygenic risk score for hypertension associates with preeclampsia. However, comparison with gestational hypertension indicates that additional factors modify the risk of preeclampsia.

Can postpartum pelvic floor muscle training reduce urinary and anal incontinence?: An assessor-blinded randomized controlled trial

BACKGROUND

Pelvic floor dysfunction, including urinary and anal incontinence, is a common postpartum complaint and likely to reduce quality of life.

OBJECTIVE

To study the effects of individualized physical therapist-guided pelvic floor muscle training in the early postpartum period on urinary and anal incontinence and related bother, as well as pelvic floor muscle strength and endurance.

MATERIALS AND METHODS

This was an assessor-blinded, parallel-group, randomized controlled trial evaluating effects of pelvic floor muscle training by a physical therapist on the rate of urinary and/or anal leakage (primary outcomes); related bother and muscle strength and endurance in the pelvic floor were secondary outcomes. Between 2016 and 2017, primiparous women giving birth at Landspitali University Hospital in Reykjavik, Iceland, were screened for eligibilty 6-10 weeks after childbirth. Of those identified as urinary incontinent, 95 were invited to participate, of whom 84 agreed. The intervention, starting at ∼9 weeks postpartum consisted of 12 weekly sessions with a physical therapist, after which the main outcomes were assessed (endpoint, ∼6 months postpartum). Additional follow-up was conducted at ∼12 months postpartum. The control group received no instructions after the initial assessment. The Fisher exact test was used to test differences in the proportion of women with urinary and anal incontinence between the intervention and control groups, and independent-sample t tests were used for mean differences in muscle strength and endurance. Significance levels were set as α = 0.05.

RESULTS

A total of 41 and 43 women were randomized to the intervention and control groups, respectively. Three participants and 1 participant withdrew from these respective groups. Measurement variables and main delivery outcomes were not different at recruitment. At the endpoint, urinary incontinence was less frequent in the intervention group, with 21 participants (57%) still symptomatic, compared to 31 controls (82%) (P = .03), as was bladder-related bother with 10 participants (27%) in the intervention vs 23 (60%) in the control group (P = .005). Anal incontinence was not influenced by pelvic floor muscle training (P = .33), nor was bowel-related bother (P = .82). The mean differences between groups in measured pelvic floor muscle strength changes at endpoint was 5 hPa (95% confidence interval, 2-8; P = .003), and for pelvic floor muscle endurance changes, 50 hPa/s (95% confidence interval, 23-77; P = .001), both in favor of the intervention group. The mean between-group differences for anal sphincter strength changes was 10 hPa (95% confidence interval, 2-18; P = .01) and for anal sphincter endurance changes 95 hPa/s (95% confidence interval, 16-173; P = .02), both in favor of the intervention. At the follow-up visit 12 months postpartum, no differences were observed between the groups regarding rates of urinary and anal incontinence and related bother. Pelvic floor- and anal muscle strength and endurance favoring the intervention group were maintained.

CONCLUSION

Postpartum pelvic floor mucle training decreased the rate of urinary incontinence and related bother 6 months postpartum and increased muscle strength and endurance.

Effects of an intervention program for reducing severe perineal trauma during the second stage of labor

BACKGROUND

Obstetric anal sphincter injuries lead frequently to short- and long-term consequences for the mother, including perineal pain, genital prolapse, and sexual problems. The aim of the study was to evaluate whether the implementation of an intervention program in the second stage of labor involving altered perineal support techniques reduced severe perineal trauma.

METHODS

All women reaching the second stage of labor and giving birth vaginally to singleton babies at Landspítali University Hospital (comprising 76% of births in Iceland in 2013) were enrolled in a cohort study. Data were recorded retrospectively for 2008-2010 and prospectively in 2012-2014, for a total of 16 336 births. During 2011, an intervention program was implemented, involving all midwives and obstetricians working in the labor wards. Two professionals assessed and agreed on classification of every perineal tear.

RESULTS

The prevalence of obstetric anal sphincter injuries decreased from 5.9% to 3.7% after the implementation (P < 0.001). Third-degree tears decreased by 40%, and fourth-degree tears decreased by 56% (P < 0.001). The prevalence of first-degree tears increased from 25.8% to 33.1%, whereas second-degree tears decreased from 44.7% to 36.6% between the before and after study periods. Severe perineal trauma was linked to birthweight, and this did not change despite the new intervention.

CONCLUSIONS

Active intervention to reduce perineal trauma was associated with an overall significant decrease in obstetric anal sphincter injuries. Good perineal visualization, manual perineal support, and controlled delivery of the fetal head were essential components for reducing perineal trauma.

Variants associating with uterine leiomyoma highlight genetic background shared by various cancers and hormone-related traits

Uterine leiomyomas are common benign tumors of the myometrium. We performed a meta-analysis of two genome-wide association studies of leiomyoma in European women (16,595 cases and 523,330 controls), uncovering 21 variants at 16 loci that associate with the disease. Five variants were previously reported to confer risk of various malignant or benign tumors (rs78378222 in TP53, rs10069690 in TERT, rs1800057 and rs1801516 in ATM, and rs7907606 at OBFC1) and four signals are located at established risk loci for hormone-related traits (endometriosis and breast cancer) at 1q36.12 (CDC42/WNT4), 2p25.1 (GREB1), 20p12.3 (MCM8), and 6q26.2 (SYNE1/ESR1). Polygenic score for leiomyoma, computed using UKB data, is significantly correlated with risk of cancer in the Icelandic population. Functional annotation suggests that the non-coding risk variants affect multiple genes, including ESR1. Our results provide insights into the genetic background of leiomyoma that are shared by other benign and malignant tumors and highlight the role of hormones in leiomyoma growth.

Uterine leiomyomas are common benign tumors. Here, a meta-analysis of two European leiomyoma GWAS uncovers 21 leiomyoma risk variants at 16 loci, providing evidence of genetic overlap between leiomyoma and various benign and malignant tumors and highlighting the role of estrogen in tumor growth.

Paternity Change and the Recurrence Risk in Familial Hypertensive Disorder in Pregnancy

OBJECTIVE

To investigate if there is an increased risk for recurrence of hypertensive disorder in pregnancy with a new partner and whether this is affected by maternal age and the interbirth interval through use of familial material.

METHODS

Data on 614 multiparous women, with confirmed de novo hypertensive disorder in a first pregnancy, were used to assess the effect of paternity and interbirth interval on recurrence of hypertensive disorders.

RESULTS

There were 121 women (19.7%) who had changed partner. Recurrent hypertension occurred in 318 women (64.5%) with the same partner and in 75 women (62%) with a new partner. The odds ratio (OR) for recurrence with the same partner was 1.115 (95% CI 0.739-1.680) and with a new partner 0.897 (95% CI 0.595-1.353). The mean interbirth interval was longer for women with recurrent hypertension (4.9 vs. 4.0 years, p = 0.0002). The OR for developing recurrent hypertensive disorder was 1.154 (95% CI 1.049-1.269) for every interval year with the same partner and 1.145 (95% CI 0.958-1.368) with a new partner after correction for maternal age.

CONCLUSION

In women with a positive family history and previous hypertension in pregnancy, change of paternity does not influence the risk of recurrence. Increasing interbirth interval may account for a 15% recurrence risk for each year, independent of maternal age. There was no indication that a change of partner conferred any influence on the recurrence risk that is not explained with birth interval or age.

Variants in the fetal genome near FLT1 are associated with risk of preeclampsia

Preeclampsia, which affects approximately 5% of pregnancies, is a leading cause of maternal and perinatal death. The causes of preeclampsia remain unclear, but there is evidence for inherited susceptibility. Genome-wide association studies (GWAS) have not identified maternal sequence variants of genome-wide significance that replicate in independent data sets. We report the first GWAS of offspring from preeclamptic pregnancies and discovery of the first genome-wide significant susceptibility locus (rs4769613; P = 5.4 × 10^-11) in 4,380 cases and 310,238 controls. This locus is near the FLT1 gene encoding Fms-like tyrosine kinase 1, providing biological support, as a placental isoform of this protein (sFlt-1) is implicated in the pathology of preeclampsia. The association was strongest in offspring from pregnancies in which preeclampsia developed during late gestation and offspring birth weights exceeded the tenth centile. An additional nearby variant, rs12050029, associated with preeclampsia independently of rs4769613. The newly discovered locus may enhance understanding of the pathophysiology of preeclampsia and its subtypes.

Meta-analysis identifies five novel loci associated with endometriosis highlighting key genes involved in hormone metabolism

Endometriosis is a heritable hormone-dependent gynecological disorder, associated with severe pelvic pain and reduced fertility; however, its molecular mechanisms remain largely unknown. Here we perform a meta-analysis of 11 genome-wide association case-control data sets, totalling 17,045 endometriosis cases and 191,596 controls. In addition to replicating previously reported loci, we identify five novel loci significantly associated with endometriosis risk (P<5 × 10⁻⁸), implicating genes involved in sex steroid hormone pathways (FN1, CCDC170, ESR1, SYNE1 and FSHB). Conditional analysis identified five secondary association signals, including two at the ESR1 locus, resulting in 19 independent single nucleotide polymorphisms (SNPs) robustly associated with endometriosis, which together explain up to 5.19% of variance in endometriosis. These results highlight novel variants in or near specific genes with important roles in sex steroid hormone signalling and function, and offer unique opportunities for more targeted functional research efforts.

Endometriosis is a major cause of infertility. Molecular mechanisms underlying the disease involve genetic and environmental risk factors. In a meta-analysis of eleven GWA studies, Sapkota and colleagues identify five novel risk loci, implicating steroid sex hormone pathways in the pathogenesis.

Physical activity of relatively high intensity in mid-pregnancy predicts lower glucose tolerance levels

INTRODUCTION

Physical activity (PA) is recommended as part of therapy for patients with impaired glucose tolerance. Whether such recommendations are also justified for pregnant women is less well established. We investigated the association between PA and glucose tolerance in pregnancy.

MATERIAL AND METHODS

A non-selective sample of 217 pregnant women was recruited at a routine 20 week ultrasound examination. Participants answered the International Physical Activity Questionnaire (IPAQ) about frequency, intensity and duration of daily physical activity in the past 7 days and underwent oral glucose tolerance testing (OGTT) between 24 and 28 weeks. A subset of 72 overweight/obese pregnant women wore a pedometer for 1 week with assessment of IPAQ score and pedometric correlations to this.

RESULTS

Of the sample, 177 attended for OGTT; 51% were overweight or obese. The mean (SD) fasting glucose was 4.5 (0.4) mmol/L, and 12% had gestational diabetes mellitus. Only one-third engaged in vigorous PA. After adjustment for pre-pregnancy BMI, age and parity, those engaging in vigorous PA had significantly lower fasting glucose levels (by 0.15 mmol/L, 95% CI 0.03-0.27) compared with those not vigorously active. This decrease was similar in both normal and overweight/obese women. There were fewer cases of gestational diabetes (p = 0.03) among the vigorously active women (3/56; 5%) than among those who were not active (19/121; 16%). No association with glucose tolerance was observed for physical activity of moderate intensity.

CONCLUSIONS

Only vigorous physical activity appears beneficial with respect to maternal glucose tolerance, both among normal, overweight and obese women.

Mode of delivery and subsequent reproductive patterns. A national follow-up study

OBJECTIVE

To investigate associations between mode of delivery and subsequent reproductive outcomes.

DESIGN

Cohort study.

POPULATION

Women with term singleton live births from 1987 to 2009.

SETTING

Denmark, birth registration data.

METHODS

Women with a first singleton delivery after 37 weeks were followed until the end of 2010, from a first birth to include subsequent live births. We used Cox's proportional hazards model stratified by parity to compare the likelihood for subsequent delivery according to mode of delivery at first and later births, estimating maternal age effects and lag time to next delivery.

MAIN OUTCOME MEASURE

Likelihood of a subsequent live-born child by previous delivery mode.

RESULTS

We identified 642,052 women with a first delivery. Compared with women with a non-instrumental vaginal delivery, delivering a child by elective cesarean section implied a 23% (95% CI 0.76-0.787) decreased likelihood for subsequent delivery. Emergency cesarean section meant 16% fewer (95% CI 0.84-0.85), and vaginal instrumental delivery 4% fewer subsequent deliveries (95% CI 0.95-0.96). Hazard ratios were largely unchanged after controlling for parity and year of birth. Small age-trends were seen, with hazard ratios affected by maternal age at birth. Delivery mode at first birth affected marginally the time lag until next birth.

CONCLUSIONS

Fecundity, measured as likelihood of a successive live-born child, varied with mode of delivery at the first and also subsequent births. A first or later delivery by cesarean section implied decreased likelihood of subsequent delivery compared with women with a first vaginal birth.

Recurrence of hypertensive disorder in second pregnancy

OBJECTIVE

The purpose of this study was to investigate the recurrence of hypertensive disorders in pregnancy with regard to the type of disorder, the onset of hypertension, and the modulating effect of overweight and weight gain between pregnancies.

STUDY DESIGN

Maternity records from 896 parous women with hypertensive disorders in pregnancy in the first pregnancy were reviewed to reclassify disease status and calculate odds ratios for recurrence.

RESULTS

Recurrence of hypertensive disorders in pregnancy occurred in 58% to 94% of second pregnancies, depending on first pregnancy disorder. Overweight (odds ratio, 1.82) and weight gain (odds ratio, 2.20) were related to recurrence among women with gestational hypertension. Early hypertension (<or =34 weeks of gestation) increased the recurrence risk for women with gestational hypertension (odds ratio, 1.85) and preeclampsia (odds ratio, 3.42).

CONCLUSION

Recurrence of hypertensive disorders in pregnancy is common, but not specified by type of disorder in first pregnancy. Overweight and weight gain between pregnancies are associated with recurrent hypertensive disorders in pregnancy in women with gestational hypertension. Early onset of hypertension is a risk factor, independent of body weight.

Quantitative DNA perturbations of p53 in endometriosis: analysis of American and Icelandic cases

OBJECTIVE

To investigate quantitative aberrations involving p53 copy numbers in eutopic endometrial and endometriotic tissue from two populations.

DESIGN

Comparative analysis of normal and diseased tissue.

SETTING

Tissue specimens collected in Iceland and USA.

PATIENT(S)

Subjects with moderate/severe endometriosis (Iceland, n = 26; USA, n = 45). Paraffin-embedded tissue from 19 matched Icelandic cases and seven unaffected controls. American cases were fresh surgical tissue from 17 matched cases and 28 unaffected controls. DNA isolation and real-time polymerase chain reaction (PCR) with TaqMan assay were performed.

MAIN OUTCOME MEASURE(S)

The frequency of p53 loss and/or gain based on quantitative differences for copy numbers of p53 located on chromosome (17p) and GAPDH on a control locus (chromosome 12p).

RESULT(S)

Among American cases, significant p53 gain (n = 13) or loss (n = 4) was observed in 17 of 21 cases. In Icelandic cases this was not seen to the same degree. Mean normalized p53 values were 3.46 and 1.16 copies per reaction, respectively. Significant differences were observed between normalized p53 in the control blood and affected tissue for the American and Icelandic cases compared to standard GAPDH control but not in normal Icelandic and American endometrium.

CONCLUSION(S)

The results continue to support a role for nonrandom somatic p53 locus alterations in the pathogenesis of late or severe-stage endometriosis. Differences between Icelandic and American subjects have implications for generalization of genome-wide approaches.

Cardiovascular death in women who had hypertension in pregnancy: a case-control study

OBJECTIVE

To determine whether an association exists between hypertension in pregnancy and later development of cardiovascular disease.

DESIGN

Case-control study of women who delivered with and without hypertensive complications during the same period.

SETTING

University Hospital in Reykjavik, Iceland.

POPULATION

Three hundred and twenty-five women with hypertension in pregnancy (blood pressure > or =140/90 mmHg after 20 weeks of gestation) in the years 1931-1947, graded by severity. For each case, two normotensive control women, delivering before or after the case and matched for parity and age were selected, giving a total of 629 women.

METHODS

Causes of death were evaluated for the presence of ischaemic heart disease, cerebrovascular events and cancer, up until the end of 1996.

MAIN OUTCOME MEASURES

Survival curves, median survival times, risk of death by age group and severity of disease.

RESULTS

Death with evidence of ischaemic heart disease was more common in cases (24.3%) than in control women (14.6%) (RR 1.66; 95% CI 1.27-2.17). Cerebrovascular event deaths occurred in 9.5% of cases and in 6.5% of controls (RR 1.46; 95% CI 0.94-2.28). Cancer death rates were not different (RR 1.22; 95% CI 0.91-1.63). Survival times were shorter on average by three to nine years as a consequence of cardiovascular disease. This varied by age group in the index pregnancy for women with a history of hypertension in pregnancy. The effect was smaller if the case pregnancy occurred at a young age. There was a linear trend with increasing severity of hypertensive disease in pregnancy in death rates from ischaemic heart disease (chi(2) (1)= 5.8, P= 0.02).

CONCLUSIONS

Long term follow up suggests an increased risk of death from ischaemic heart disease and cerebrovascular events among women who suffered hypertension in pregnancy.

Association of fish and fish liver oil intake in pregnancy with infant size at birth among women of normal weight before pregnancy in a fishing community

This 1998 study investigated the association between intake of fish and fish oil during pregnancy and full-term infants' size at birth in an Icelandic fishing community. Healthy women aged 20-40 years of normal weight before pregnancy (body mass index: 19.5-25.5 kg/m(2)) and at 38-43 weeks of gestation were selected randomly. Information on infant size at birth was collected from maternity records. Intake of fish and fish oil in pregnancy was ascertained (n = 491, 80.1%) by using a validated, focused, food frequency questionnaire. Infants of women in the lowest quartile of fish consumption weighed less (p = 0.036), were shorter (p < 0.001), and had a smaller head circumference (p < 0.001) at birth than those of women consuming higher amounts of fish. Infants of women in the highest quartile of fish oil intake (> or =1 tablespoon (11 ml)/day), consuming threefold the recommended dietary allowance of vitamin A and twofold that of vitamin D, were shorter (p = 0.036) and had a smaller head circumference (p = 0.003) than those of women consuming less. Infant size at birth increased with fish consumption, especially for women in the lower quartiles of consumption. Smaller birth size was linked to the highest levels of fish oil intake. Constituents of fish and fish oil might affect birth size differently depending on the amount consumed.

Effectiveness of preabortion counseling on postabortion contraceptive use

In a randomized trial, the effect of preabortion counseling was evaluated and contraceptive use postabortion described. The 420 women, who were assigned into either an intervention group (n = 210) or a control group (n = 210), were followed-up 4-6 months later, a total of 148 and 128 women in each respective group. No significant difference was found between the two groups regarding contraceptive use after abortion (86%, 85%), which indicates no immediate intervention effect. The women, in both groups, who had previously undergone abortion were less likely to use contraception. The main contraceptive methods used by intervention and control groups were oral contraceptives (61% and 58%, respectively) and injectables (12% and 11%). Choice of method was mainly based on women's prior perception of effectiveness and convenience of use. A majority of the women in both groups could not specify their contraceptive plans. A postrandomization inequality regarding age, education and parity in the two groups had, however, to be taken into account. Intensive contraceptive counseling before abortion may not be effective, but those who are at higher risk of unplanned pregnancy need special attention.

The contraceptive vaginal ring (NuvaRing®) and hemostasis: a comparative study

This open-label, nonrandomized study compared changes in hemostatic variables during NuvaRing and oral levonorgestrel 150 microg/ethinylestradiol 30 microg (LNG/EE) use for six cycles. Eighty-seven women started the study, 44 with NuvaRing and 43 with the LNG/EE oral contraceptive. For most procoagulation variables, there was no difference between NuvaRing and oral LNG/EE; only Factor VII levels increased in the NuvaRing group and decreased in the LNG/EE group. The majority of assessed variables show that anticoagulation and fibrinolytic activity was comparable between the NuvaRing and oral LNG/EE groups. Antithrombin activity and protein C activity both tended to be higher with NuvaRing. Levels of tissue plasminogen activator decreased in both groups but the reduction was smaller with NuvaRing. There were no significant differences in fibrin turnover between the treatment groups. The data show that both NuvaRing and oral LNG/EE are associated with a minimal effect on hemostatic variables.

Trends in teenage fertility, abortion, and pregnancy rates in Iceland compared with other Nordic countries, 1976-99

BACKGROUND

Iceland is often considered very similar to the other Nordic countries. The purpose of this study was to explore trends in teenage fertility, abortion, and pregnancy rates in Iceland, compare these trends with corresponding rates in Denmark, Finland, Norway, and Sweden during the period 1976-99, and to evaluate similarities and dissimilarities.

METHODS

The study is based on data about fertility, abortion, and pregnancy rates obtained from the Icelandic and Nordic national population and abortion registers for the age group 15-19 years years.

RESULTS

Teenage fertility and pregnancy rates in the five Nordic countries declined over the study period by 57-67% and 31-50%, respectively, and in Iceland they remained significantly higher than in the Nordic countries. In 1999 almost every other teenage pregnancy in Iceland (45.9/1000) resulted in a childbirth (24.4/1000). Regional fertility rates were highest in the countryside. While the abortion rate has been declining in the four Nordic countries by 20-41%, they have concurrently been rising in Iceland by 133% (9.4/1000 in 1976-80, 21.9/1000 in 1996-99) and are presently higher than in the other Nordic countries. Regionally, abortion rates in Iceland were highest in the Capital area.

CONCLUSIONS

The teenage pregnancy rate is higher in Iceland than in the other Nordic countries. This may be explained by cultural norms in Iceland's society regarding childbearing, early initiation of sexual intercourse, more limited sex education, and less effective delivery and use of contraceptive methods. There is a need to promote sexual and reproductive health to young people in Iceland by combining diverse preventive approaches.

Weight gain in women of normal weight before pregnancy: complications in pregnancy or delivery and birth outcome

OBJECTIVE

To investigate the relation between gestational weight gain in women of normal prepregnant weight and complications during pregnancy and delivery in a population with high gestational weight gain and birth weight.

METHODS

Healthy women (n = 615) of normal weight before pregnancy (body mass index 19.5-25.5 kg/m(2)) were randomly selected. Maternity records gave information on age, height, prepregnant weight, gestational weight gain, parity, smoking, gestational hypertension and diabetes, preeclampsia, delivery complications, and infants' birth size and health.

RESULTS

The mean weight gain in pregnancy was 16.8 +/- 4.9 kg (mean +/- standard deviation). A total of 26.4% of the women had complications, either in pregnancy (9.1%) or delivery (17.3%). Women gaining weight according to the recommendation of the Institute of Medicine (11.5-16.0 kg) had lower frequency of pregnancy-delivery complications than women gaining more than 20.0 kg (P =.017), but did not differ significantly from those gaining 16-20 kg (P >.05). When dividing weight gain in pregnancy into quintiles, a relative risk of 2.69 (95% confidence interval 1.01, 7.18, P =.048) was found for complications in pregnancy in the fourth quintile (17.9-20.8 kg), using the second quintile as reference (12.5-15.5 kg). The mean birth weight was 3778 +/- 496 g. A low weight gain in pregnancy (less than 11.5 kg) was associated with an increased frequency of infants weighing less than 3500 g at birth (P <.01).

CONCLUSION

A gestational weight gain of 11.5-16.0 kg (Institute of Medicine recommendation) for women of normal prepregnant weight is related to the lowest risk for pregnancy-delivery complications. In the population studied, the upper limit might be higher (up to 18 kg), and low weight gain should be avoided to optimize birth outcome.

Genetic factors contribute to the risk of developing endometriosis

BACKGROUND

Endometriosis is known to cluster within nuclear families. The extent of familial clustering can be evaluated in Iceland with its large population-based genealogical database.

METHODS AND RESULTS

Applying several measures of familiality we demonstrated that 750 women with endometriosis were significantly more interrelated than matched control groups. The risk ratio for sisters was 5.20 (P < 0.001) and for cousins 1.56 (P = 0.003). The average kinship coefficient for the patients was significantly higher than that calculated for 1000 sets of 750 matched controls (P < 0.001) and this remained significant when contribution from first-degree relatives was excluded (P < 0.05). The minimum number of ancestors required to account for the group of patients was compared with the minimum number of ancestors required to account for the control groups at different time points in the past. The minimum number of founders for the group of patients was significantly smaller than for the control groups. Affected cousin pairs were as likely to be paternally connected as maternally connected.

CONCLUSIONS

This is the first population-based study using an extensive genealogy database to examine the genetic contribution to endometriosis. A genetic factor is present, with a raised risk in close and more distant relatives, and a definite kinship factor with maternal and paternal inheritance contributing.

Comparative study of the effects of a progestogen-only pill containing desogestrel and an intrauterine contraceptive device in lactating women

OBJECTIVE

To evaluate the effects of desogestrel 75 microg/day, as a progestogen-only pill compared with a copper-bearing intrauterine contraceptive device (IUCD) on lactation and to study the safety of both treatments in mothers and children. Transfer of etonogestrel to breast milk was studied in a subgroup of desogestrel users. The children were to be followed up until 2.5 years of age.

DESIGN

An open, non-randomised, group-comparative study in lactating women.

SETTING

University Hospital, Reykjavik, Iceland.

PARTICIPANTS

A total of 83 lactating women; 42 received desogestrel and 41 had an IUCD inserted for seven consecutive treatment cycles of 28 days.

METHODS

Evaluation visits were planned at baseline and at the end of treatment cycles 1, 4 and 7. The amount of breast milk was determined by weighing the infants before and after feeding, at baseline and after treatment cycles I and 4. Milk samples were obtained at the same time for constituent measurements. Safety was studied by structured medical examinations and by recording adverse experiences in mothers and children.

RESULTS

There were no significant differences between the desogestrel and IUCD groups in composition and quantity of breast milk nor in growth and development of the children followed up to the age of 2.5 years. In the desogestrel group a slightly higher incidence of mild adverse experiences of a hormonal nature was reported among both mothers and infants. Of the children 82% were followed until 1.5 years of age and 50% until 2.5 years.

CONCLUSION

The use of desogestrel 75 microg/day did not change the amount and composition of breast milk nor did it affect growth and development of the breastfed children. It appears to be a safe and effective contraceptive method for lactating women

Endometriosis is not associated with or linked to the GALT gene

OBJECTIVE

To investigate a possible association between the carrier frequency of the N314D mutation in the galactose-1-phosphate uridyl transferase (GALT) gene and endometriosis and linkage to the short arm of chromosome 9, where the GALT gene resides.

DESIGN

Association and linkage study.

SETTING

Population material collected for case and family studies in endometriosis.

PATIENT(S)

Women diagnosed with endometriosis by laparotomy or laparoscopy.

INTERVENTION(S)

Association with the GALT gene investigated by genotyping 85 affected women and 213 unrelated control women and a scan for linkage to chromosome 9 in 205 women from 64 families with endometriosis.

MAIN OUTCOME MEASURE(S)

Multipoint parametric lod scores and frequency of alleles.

RESULT(S)

There was no significant difference in allele frequency for the N314D polymorphism in patients compared with control subjects. No evidence for linkage was found to chromosome 9p, where the GALT gene resides.

CONCLUSION(S)

The experiments reported herein provide no evidence supporting involvement of the GALT locus in the development of endometriosis.

[Ultrasound screening at 18-20 weeks.]

Ultrasound screening at 18-20 weeks gestation is widely recognized as an integral part of modern antenatal care. It was set up in Iceland between 1984 and 1986 and has become steadily more advanced. The time for this basic dating and fetal assessment scan was selected in accordance with current medical knowledge, based on several cohort studies, later supplemented by results from randomized trials. Icelandic reference standards were established and the suitability of mostly Scandinavian fetal assessment methods for the Icelandic population was evaluated. Gestational age assessment and placental localisation, along with a thoroughly performed evaluation to ascertain normal fetal anatomy, were conducted systematically. Icelandic guidelines and educational standards for conducting ultrasound were published. As most deviations from the normal, including major anomalies, are found in those not perceived to be at risk, a screening approach was necessary. Better dating of pregnancies and prenatal diagnosis allowing either termination of pregnancy in case of severe fetal anomaly or preparation for correct handling of the neonate at birth, have had a major impact on obstetric practice. Most lethal or seriously handicapped fetuses are detected. The screening scan has become a universally accepted and appreciated part of antenatal care in Iceland.

Dyslipoproteinaemia in postmenopausal women with a history of eclampsia

OBJECTIVE

To test the hypothesis that postmenopausal women with a history of eclampsia manifest a more high risk lipid profile than postmenopausal women with a history of normal pregnancy.

SETTING

The Department of Obstetrics and Gynaecology, National University Hospital, Reykjavik, Iceland, and the Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA.

PARTICIPANTS

Thirty Icelandic women with a history of eclampsia, aged between 50 and 67 years at the time of re-examination (cases) were individually matched for current age, and for age and parity at index pregnancy, to 30 unrelated Icelandic women with a history of normal pregnancy (controls).

METHODS

The participating women completed a health and family history questionnaire and underwent a physical examination. Fasting plasma low density lipoprotein diameter, serum lipids, insulin, and glucose were measured.

RESULTS

Mean low density lipoprotein size was significantly smaller and apolipoprotein B concentration was higher in women with prior eclampsia. The percentage of cases receiving blood pressure medication (33%) was significantly greater than controls (6.7%). Thirteen cases had had hypertensive complications in at least one other pregnancy (recurrent subgroup); postmenopausally, these women displayed significantly increased diastolic blood pressures, smaller-sized low density lipoprotein, increased apolipoprotein B, decreased high density lipoprotein2 (HDL2) cholesterol, and increased total cholesterol: HDL cholesterol ratio compared with their controls. Fourteen cases were normotensive in all other pregnancies (nonrecurrent); these showed no differences from their controls.

CONCLUSIONS

Dyslipoproteinaemia is more prevalent among postmenopausal women with prior eclampsia, especially with recurrent hypertension in pregnancy, than in postmenopausal women with prior normal pregnancies.

Effects of fetal and maternal breathing on the ultrasonic Doppler signal due to fetal heart movement

Fetal heart rate (FHR) monitoring is widely used to evaluate fetal health and is based on the detection of movements of the fetal heart by Doppler ultrasound. Fetal health can also be evaluated by prolonged observation of body- and pseudo-respiratory movements using two-dimensional ultrasound. Fetal breathing movements are in particular considered to be an important indicator of fetal well being. Ultrasonic Doppler signals caused by movements of the fetal heart were analyzed in detail. The signals were acquired from five healthy fetuses. Minor changes in the insonification geometry gave rise to great variations in the aspects of successive heartbeats. The signals are shown to contain information on both maternal and fetal respiratory movements. This may facilitate the development of a simple method for fetal respiration monitoring coupled to standard FHR monitoring.

[Ectopic pregnancy in Iceland 1985-1994.]

OBJECTIVE

Ectopic pregnancy (EP) has increased during the last two-three decades and diagnostic tests and treatment have changed. Two previous studies on ectopic pregnancy have been published in Iceland. A study was initiated to evaluate changes over a new 10 year period.

MATERIAL AND METHODS

All cases of histologically confirmed ectopic pregnancy during a 10 year period 1985-1994 were reviewed. Age, previous normal and ectopic pregnancies, diagnosis by ultrasound and use of intrauterine contraceptive device (IUCD), infertility problems, pelvic inflammatory disease, site of implantation and operative procedures were recorded. Rates were calculated against the background of numbers of women of reproductive age (15-44) and of pregnancies for each year and in five-year periods.

RESULTS

There were 1267 cases of EP with a doubling of the incidence (p for trend <0.001). There were more women of fertile age and a higher pregnancy rate in the population, but still a significant rise in incidence and prevalence above this. The age group 25-29 years was most common in 1985-1989, but 30- 34 years in 1990-1994. EP was a first pregnancy in 12.9% of cases during 1985-1989 and 15.8% in 1990- 1994. The total number of women with a previous EP rose between five-year periods. A repeated EP occurred in 16.5%, most commonly in the age 30-34 years. There were 104 women with two EPs, 44 with three, 14 with four, two with five and one each with six, seven and eight. Implantation was more often on the right side (p<0.0001). In 1.1% tuba1 sterilization had been done. Ultrasound was increasingly used as a diagnostic tool; for 68.4% of the women in the second period. Women with infertility totalled 27%. In 17% the women had an IUCD. Ovarian EP was only seen in eight cases (0.63%) and abdominal EP in two. Surgical procedures changed significantly with laparoscopic techniques being used increasingly.

CONCLUSIONS

The incidence of EP has increased in Iceland until in the most recent years. Treatment has changed and the need for longer hospitalisation declined.

[Perinatal death classification in Iceland 1994-1998.]

OBJECTIVE

To analyse perinatal deaths in Iceland (>22 weeks or 500 g) over a five year period by a new Nordic classification.

MATERIAL AND METHODS

Medical records for all cases of perinatal death in Iceland from 1994-1998 were analysed. A classification focussing on potential avoidability from a health service perspective was used to identify major groups and areas for improvement. The classification is based on the following variables: time of death in relation to admission and delivery, fetal malformation, gestational age, growth-retardation and Apgar score at five minutes.

RESULTS

One hundred and fifty-eight perinatal deaths occurrecl. Of these 103 (65%) were stillborn babies and 55 were early neonatal deaths. The cumulative perinatal mortality rate (PNMR) was 7.3/1000 births for the period and all perinatal deaths, but using a cut-off point >28 weeks or 1000 g this was lower, 5.1/1000. Potentially avoidable groups accounted for 12% of the perinatal deaths, i.e. growthretarded singletons after >28 weeks and intrapartum deaths after >28 weeks. Almost half of the perinatal deaths (41.1%) could probably not be prevented with present methods in perinatal care. These included intrauterine deaths of non-growth retarded singletons after 28 weeks (27.8%) and intrauterine deaths be-fore 28 weeks, still considered miscarriages in some countries (13.3%). Two-thirds of the early neonatal.

CONCLUSIONS

The Nordic classification used gave a good picture of the causes of avoidable and unavoidable perinatal deaths and may facilitate comparison between populations and periods.

A genome-wide scan reveals a maternal susceptibility locus for pre-eclampsia on chromosome 2p13

Pre-eclampsia is a common and serious disease and a major cause of maternal and infant mortality. Antenatal care systems world-wide screen for signs of the disease such as hypertension and proteinuria. Unlike most other human disorders it impacts two individuals, the mother and the child, both of whom can be severely affected. The pathophysiology of the disorder is incompletely understood, but familial clustering of the disease is apparent. Here we report the results of a genome-wide screen of Icelandic families representing 343 affected women. Including those patients with non-proteinuric pre-eclampsia (gestational hypertension), proteinuric pre-eclampsia and eclampsia, we detected a significant locus on 2p13 with a lod score of 4.70 (single point P < 3.49 x 10(-6)). This is the first reported locus for pre-eclampsia meeting the criteria for genome-wide significance.

Humerospinous distance measurements: accuracy and usefulness for predicting shoulder dystocia in delivery at term

OBJECTIVE

To investigate if the humerospinous distance, as an indicator of shoulder width, could predict shoulder dystocia at term.

DESIGN

Prospective cross-sectional study of a stratified reference group of healthy women and a test group of women with risk factors for shoulder dystocia. Measurements were not revealed. Outcome measures were difficulties with delivery of the shoulders and correlation with maternal body mass and birth weight.

SUBJECTS

Seventy-two women with singleton pregnancies at a University Clinic: 32 women at 39-42 weeks for reference and 40 women in an at-risk test group (weight > 90 kg, weight gain > 20 kg, previous macrosomic baby, history of shoulder dystocia/difficult delivery, clinical suspicion of a large baby). Women with a breech fetus, twins and those not able to deliver vaginally were excluded.

METHODS

Fetal shoulders were measured from the convergence of the cervical spinous processes at the approximate cervicothoracic vertebral junction to the medial border of the humeral head. Correlations were made with maternal body mass, birth weight, birth weight estimation, ultrasound and postnatal humerospinous measurements.

RESULTS

One case of shoulder dystocia in a fetus with an average humerospinous measurement occurred in the reference group and there were no cases in the test group. There was no predictive value of a large humerospinous measurement and no correlation with maternal or fetal size. Movement of the fetal arm could change the humerospinous distance considerably, which could account for the difference between a normal and large measurement.

CONCLUSION

The humerospinous distance cannot be used to predict shoulder dystocia.