Association between healthy maternal dietary pattern and risk for gestational diabetes mellitus.

BACKGROUND/OBJECTIVES: Gestational diabetes mellitus (GDM) is associated with negative health effects for mother and child. The aim was to investigate the association between maternal dietary patterns and GDM. SUBJECTS/METHODS: Prospective observational study including 168 pregnant women aged 18-40 years, recruited at routine 20-week ultrasound. All participants kept a 4-day weighed food record following recruitment (commencement: gestational weeks 19-24). Principal component analysis was used to extract dietary patterns from 29 food groups. A Healthy Eating Index (HEI) was constructed. All women underwent an oral glucose tolerance test in weeks 23-28. RESULTS: One clear dietary pattern (Eigenvalue 2.4) was extracted with positive factor loadings for seafood; eggs; vegetables; fruits and berries; vegetable oils; nuts and seeds; pasta; breakfast cereals; and coffee, tea and cocoa powder, and negative factor loadings for soft drinks and French fries. This pattern was labeled a prudent dietary pattern. Explained variance was 8.2%. The prevalence of GDM was 2.3% among women of normal weight before pregnancy (n=86) and 18.3% among overweight/obese women (n=82). The prudent dietary pattern was associated with lower risk of GDM (OR: 0.54; 95% CI: 0.30, 0.98). When adjusting for age, parity, prepregnancy weight, energy intake, weekly weight gain and total metabolic equivalent of task the association remained (OR: 0.36; 95% CI: 0.14, 0.94). Similar results were found when only including overweight or obese women (OR: 0.31; 95% CI: 0.13, 0.75). CONCLUSIONS: Adhering to a prudent dietary pattern in pregnancy was clearly associated with lower risk of GDM, especially among women already at higher risk because of overweight/obesity before pregnancy.

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.

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.

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.

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

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.

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.

[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.

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.

Urinary incontinence and urinary tract infections in octogenarian women.

BACKGROUND: Urinary incontinence and urinary tract infection are common problems among elderly women due to age-related changes in the urogenital tract, but information regarding prevalence and presentation among the aged is limited. METHODS: A total of 97 randomly selected women aged 80-89 years, 47 living in homes for the elderly and 50 living at home, were asked about urogenital complaints in a structured interview. Medical records provided information about urinary tract infections and the use of estrogens. RESULTS: Urinary incontinence affected 46%; half of them daily. Urge incontinence was most common (43%), then mixed incontinence (28%) and stress incontinence (26%). Urge and mixed incontinence caused significantly more discomfort than stress incontinence. During the past two years 33% of the women had experienced urinary tract infection and 11% had > or = 5 infections. A total of 22 women were receiving estrogen treatment, more often in homes for the elderly (p < 0.001). Paradoxically, these women had a higher prevalence of urinary incontinence, urinary tract infection, and other complaints than women not receiving estrogens. Considerable or great discomfort from the urogenital tract was reported by 23% of the women. A third of the women had discussed urogenital complaints with a physician. CONCLUSION: In view of the prevalence of urogenital complaints, it is likely that more elderly women could benefit from early medical assessment and treatment. Indications for estrogen treatment need to be more clearly defined.

Evidence for a familial pregnancy-induced hypertension locus in the eNOS-gene region.

Pregnancy-induced hypertension may be regarded as a manifestation of endothelial-cell dysfunction. The role of the eNOS gene in the development of a familial pregnancy-induced hypertension was evaluated by analysis of linkage among affected sisters and in multiplex families (n = 50). Markers from a 4-cM region encoding the eNOS gene showed distortion from the expected allele sharing among affected sisters (P = .001-.05), and the statistic obtained from the multilocus application of the affected-pedigree-member method also showed distortion (T[f(P)=sqrt(P)] = 3.53; P < .001). A LOD score of 3.36 was obtained for D7S505 when a best-fitting model derived from genetic epidemiological data was used, and LOD scores of 2.54-4.03 were obtained when various other genetic models were used. Estimates of recombination rate, rather than maximum LOD-score values, were affected by changes in the genetic parameters. The transmission-disequilibrium test, a model-free estimate of linkage, showed strongest association and linkage with a microsatellite within intron 13 of the eNOS gene (P = .005). These results support the localization of a familial pregnancy-induced hypertension-susceptibility locus in the region of chromosome 7q36 encoding the eNOS gene.

Reduced prevalence of cervical Chlamydia infection among women requesting termination.

BACKGROUND: The prevalence and pattern of Chlamydia trachomatis infection among women requesting induced abortion in the three year period 1992-95 was evaluated and compared to the results of a previous study in 1982-84, where the prevalence of chlamydial infection had been 13.5%. METHODS: A total of 1995 women requested termination, 1855 (93%) of whom were tested for Chlamydia and were included in the study. Two types of tests for chlamydial infection, ELISA and PCR, were used in two consecutive periods. In addition cultures for gonorrhea were done in each case. Information on age, marital status, parity, gestational age and the results of chlamydia and gonorrhea tests of the women and sexual partners were recorded. RESULTS: Chlamydia trachomatis positive women were 149 (8.0%), a significant reduction from the previous 1982-84 study (p<0.001). Women with positive tests were significantly younger (80% < or = 25 years of age; p<0.001) and more frequently single (86.6%; p<0.001), than those with negative tests, as in the previous period. Of the partners, 80.4% were contacted, and 52.1% presented for investigation. Of those tested 42.1% were Chlamydia positive. Four women (0.2%) had Neisseria gonorrhea but none of the partners. CONCLUSIONS: The prevalence of Chlamydia trachomatis is receding among women coming for termination of pregnancy. As treatment before or at operation has repeatedly been shown to be of benefit and since the prevalence is still considerable, continued screening of these women is justified.

Obstetric outcome of natural and assisted conception twin pregnancies is similar.

BACKGROUND: The risk of obstetric intervention and adverse fetal or neonatal outcome is considerably higher in multiple gestation than in singleton pregnancy. How assisted conception influences obstetric management and outcome in twin pregnancies has not been evaluated. METHODS: A survey of all twin pregnancies in Iceland and the Tayside Region, Scotland for a four year period, 1990-93, comparing twins after assisted fertilization with natural conception. RESULTS: The total number of twin pregnancies was 522, of which 453 were natural conceptions and 69 assisted. The twin rate was 1:75 among natural conceptions, but 1:5 in women having assisted fertilization. Mean gestational age in both groups was 36 weeks. Elective Cesarean section was used more often in the assisted conception group (odds ratio 2.57; p = 0.003). Induction rates did not differ to any significant degree and once labor commenced, no difference was seen between assisted and natural conception twins in the mode of delivery or neonatal short term morbidity. Birthweight, gestational length and perinatal mortality rates by conventional and extended classification were not different. CONCLUSION: After allowing for more frequent elective Cesarean section in the obstetric care of the assisted conception pregnancies, there was no major difference in obstetric and neonatal management or outcome between twins resulting from natural and assisted conception.