Incidence and outcomes of uterine rupture in women with unscarred, preterm or prelabour uteri: data from the international network of obstetric survey systems.

OBJECTIVE: Analysis of atypical cases of uterine rupture, namely, uterine rupture occurring in unscarred, preterm or prelabour uteri. DESIGN: Descriptive multi-country population-based study. SETTING: Ten high-income countries within the International Network of Obstetric Survey Systems. POPULATION: Women with unscarred, preterm or prelabour ruptured uteri. METHODS: We merged prospectively collected individual patient data in ten population-based studies of women with complete uterine rupture. In this analysis, we focused on women with uterine rupture of unscarred, preterm or prelabour ruptured uteri. MAIN OUTCOME MEASURES: Incidence, women's characteristics, presentation and maternal and perinatal outcome. RESULTS: We identified 357 atypical uterine ruptures in 3 064 923 women giving birth. Estimated incidence was 0.2 per 10 000 women (95% CI 0.2-0.3) in the unscarred uteri, 0.5 (95% CI 0.5-0.6) in the preterm uteri, 0.7 (95% CI 0.6-0.8) in the prelabour uteri, and 0.5 (95% CI 0.4-0.5) in the group with no previous caesarean. Atypical uterine rupture resulted in peripartum hysterectomy in 66 women (18.5%, 95% CI 14.3-23.5%), three maternal deaths (0.84%, 95% CI 0.17-2.5%) and perinatal death in 62 infants (19.7%, 95% CI 15.1-25.3%). CONCLUSIONS: Uterine rupture in preterm, prelabour or unscarred uteri are extremely uncommon but were associated with severe maternal and perinatal outcome. We found a mix of risk factors in unscarred uteri, most preterm uterine ruptures occurred in caesarean-scarred uteri and most prelabour uterine ruptures in 'otherwise' scarred uteri. This study may increase awareness among clinicians and raise suspicion of the possibility of uterine rupture under these less expected conditions.

Association between blood loss at delivery and fatigue in the puerperium: a prospective longitudinal study.

Objective: The objective was to investigate the association between blood loss at delivery and physical and mental fatigue during the first 12 weeks postpartum. We also investigated the association between hemoglobin and postpartum fatigue.Methods: We performed a single center prospective longitudinal study of healthy women with a singleton delivery. Women completed the Multidimensional Fatigue Inventory and Edinburgh Postnatal Depression Scale at 3 and 7 d, 3, 8 and 12 weeks postpartum. The hemoglobin level was measured at inclusion (baseline).Results: A total of 196 women with blood loss at delivery ranging from 100 to 2800 mL were included in the study. At 12 weeks follow-up the response rate was 92% (n = 181). We found a significant association between blood loss and scores of physical and mental fatigue within the first week postpartum. When adjusted for bleeding, hemoglobin measured at inclusion was not associated with fatigue at any given time point.Conclusions: The amount of measured blood loss was significantly associated with increased physical and mental fatigue in the first week postpartum. When adjusted for bleeding, baseline hemoglobin was no longer associated with physical and mental fatigue.

Wexner score and quality of life in women with obstetric anal sphincter injury.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injury causes anal incontinence in half of the women affected. However, most symptoms are mild. The objective of this study was to evaluate the prevalence of anal incontinence and quality of life in women at long term after delivery with obstetric anal sphincter injury. We also wanted to identify a relevant cutoff level of the Wexner score (also known as the Cleveland Clinic Incontinence Score) to indicate affected quality of life in these women. METHODS: We performed a population-based questionnaire cohort study with prospective follow-up, including all women in Denmark with obstetric anal sphincter injury and one subsequent delivery between 1997 and 2005. We performed uni- and multivariate analyses and calculated the area under the ROC curve. RESULTS: In Denmark, 3885 women had an obstetric anal sphincter injury in their first delivery and a second delivery between 1997 and 2005 and no subsequent deliveries until 2010-2011. Questionnaires were sent to 3259 eligible women, and the response rate was 74.6%. In total, 2004 women could be included in the final analyses. Of these, 29.2% (n = 584) reported affected quality of life due to anal incontinence at long-term follow-up. We found that all symptoms of anal incontinence were associated with affected quality of life. The median age at follow-up was 40.3 years. The area under the ROC curve was 0.96 (95% CI 0.95-0.97) with a sensitivity of 0.94 (95% CI 0.92-0.96) and a specificity of 0.85 (95% CI 0.84-0.87) corresponding to an optimal cutoff level of the Wexner score of ≥ 2 to identify women with affected quality of life due to anal incontinence. CONCLUSIONS: In women with obstetric anal sphincter injury, 29% reported affected quality of life due to anal incontinence at long-term follow-up, and we found a low Wexner score cutoff level of ≥ 2 to identify women with affected quality of life.

Epidemiology of placenta previa accreta: a systematic review and meta-analysis.

OBJECTIVE: To estimate the prevalence and incidence of placenta previa complicated by placenta accreta spectrum (PAS) and to examine the different criteria being used for the diagnosis. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed, Google Scholar, ClinicalTrials.gov and MEDLINE were searched between August 1982 and September 2018. ELIGIBILITY CRITERIA: Studies reporting on placenta previa complicated by PAS diagnosed in a defined obstetric population. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers performed the data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with difference agreed by consensus. The primary outcomes were overall prevalence of placenta previa, incidence of PAS according to the type of placenta previa and the reported clinical outcomes, including the number of peripartum hysterectomies and direct maternal mortality. The secondary outcomes included the criteria used for the prenatal ultrasound diagnosis of placenta previa and the criteria used to diagnose and grade PAS at birth. RESULTS: A total of 258 articles were reviewed and 13 retrospective and 7 prospective studies were included in the analysis, which reported on 587 women with placenta previa and PAS. The meta-analysis indicated a significant (p<0.001) heterogeneity between study estimates for the prevalence of placenta previa, the prevalence of placenta previa with PAS and the incidence of PAS in the placenta previa cohort. The median prevalence of placenta previa was 0.56% (IQR 0.39-1.24) whereas the median prevalence of placenta previa with PAS was 0.07% (IQR 0.05-0.16). The incidence of PAS in women with a placenta previa was 11.10% (IQR 7.65-17.35). CONCLUSIONS: The high heterogeneity in qualitative and diagnostic data between studies emphasises the need to implement standardised protocols for the diagnoses of both placenta previa and PAS, including the type of placenta previa and grade of villous invasiveness. PROSPERO REGISTRATION NUMBER: CRD42017068589.

FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders.

Placenta accreta spectrum is impacting maternal health outcomes globally and its prevalence is likely to increase. Maternal outcomes depend on identification of the condition before or during delivery and, in particular, on the differential diagnosis between its adherent and invasive forms. However, accurate estimation of its prevalence and outcome is currently problematic because of the varying use of clinical criteria to define it at birth and the lack of detailed pathologic examination in most series. Adherence to this new International Federation of Gynecology and Obstetrics (FIGO) classification should improve future systematic reviews and meta-analyses and provide more accurate epidemiologic data which are essential to develop new management strategies.

Changing incidence of obstetric anal sphincter injuries-A result of formal prevention programs?

INTRODUCTION: Obstetric anal sphincter injuries (OASIS) are serious complications to vaginal delivery causing anal incontinence in 50% of the women in the long term. In Norway, the incidence of OASIS has been significantly reduced from 4%-5% to 1%-2% after implementation of prevention programs focusing on perineal protection. The aim of our study was to evaluate whether implementation of formal prevention programs was associated with a reduced incidence of OASIS over time. MATERIAL AND METHODS: We performed a historical cohort study, evaluating incidence, change of incidence and risk factors of OASIS during the years 2011-2015 at the four delivery departments in the Capital Region of Denmark. Two of the four departments implemented formal prevention programs in 2012-2013. We performed trend tests and uni- and multivariable analyses, adjusting for important risk factors and calculating interactions between risk factors. RESULTS: There were 75 173 vaginal deliveries during the study period; of those, 2670 (3.6%) were complicated by OASIS. The incidence of OASIS decreased during the study period from 4.3% (n = 636) in 2011 to 2.6% (n = 399) in 2015. There was a significant decrease in the incidence of OASIS at both the departments with formal prevention programs and those without. After adjustment for other important risk factors of OASIS, we found no significant difference in the risk reduction between departments with and without formal prevention programs. CONCLUSIONS: We found that the general focus on prevention of OASIS in Denmark was associated with a significant decrease in the incidence of OASIS, but implementation of formal prevention programs did not lead to a further reduction. It is possible that more rigorous interventions at the hospitals with formal prevention programs could have resulted in a significant difference in incidence of OASIS.

Children with dyskinetic cerebral palsy are severely affected as compared to bilateral spastic cerebral palsy.

AIM: We aimed at describing clinical findings in children with dyskinetic as compared to bilateral spastic cerebral palsy (CP). METHODS: Data were extracted from the Danish nationwide CP register. Participants were born in 1999-2007 and were 5-6 years at ascertainment. RESULTS: The total number of CP cases was 1165 of which 92 had dyskinetic and 540 bilateral spastic CP. Prevalence of dyskinetic CP was 0.16 per 1000 live births. In participants with dyskinetic compared to bilateral spastic CP, there was more frequently an Apgar level less than five at five minutes (22.7% vs. 11.2%) and neonatal seizures (43.5% vs. 28.5%), but less respiratory deficiency, hyperbilirubinaemia and sepsis. Impairment based on gross motor function classification was more severe in dyskinetic CP (level III-V 90.0% vs. 66.0%). In dyskinetic CP, there was a high rate of reduced developmental quotient (68.1%), visual impairment (39.3%) and epilepsy (51.6%). Basal ganglia lesions were more prevalent in dyskinetic compared to bilateral spastic CP (27.7% vs. 12.8%). CONCLUSION: Cases of dyskinetic CP had overlapping clinical features with cases of bilateral spastic CP, but differed significantly in several perinatal risk factors. The children with dyskinetic CP had experienced more peri- or neonatal adverse events, and neurodevelopmental impairment was severe.

Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta.

The worldwide incidence of abnormally invasive placenta is rapidly rising, following the trend of increasing cesarean delivery. It is a heterogeneous condition and has a high maternal morbidity and mortality rate, presenting specific intrapartum challenges. Its rarity makes developing individual expertise difficult for the majority of clinicians. The International Society for Abnormally Invasive Placenta aims to improve clinicians' understanding and skills in managing this difficult condition. By pooling knowledge, experience, and expertise gained within a variety of different healthcare systems, the Society seeks to improve the outcomes for women with abnormally invasive placenta globally. The recommendations presented herewith were reached using a modified Delphi technique and are based on the best available evidence. The evidence base for each is presented using a formal grading system. The topics chosen address the most pertinent questions regarding intrapartum management of abnormally invasive placenta with respect to clinically relevant outcomes, including the following: definition of a center of excellence; requirement for antenatal hospitalization; antenatal optimization of hemoglobin; gestational age for delivery; antenatal corticosteroid administration; use of preoperative cystoscopy, ureteric stents, and prophylactic pelvic arterial balloon catheters; maternal position for surgery; type of skin incision; position of the uterine incision; use of interoperative ultrasound; prophylactic administration of oxytocin; optimal method for intraoperative diagnosis; use of expectant management; adjuvant therapies for expectant management; use of local surgical resection; type of hysterectomy; use of delayed hysterectomy; intraoperative measures to treat life-threatening hemorrhage; and fertility after conservative management.

Lessons learnt from anonymized review of cases of peripartum hysterectomy by international experts: A qualitative pilot study.

Severe obstetric complications are not extensively studied and individual cases are used too little and inappropriately in quality improvement activities, due to limited numbers and prioritization of quantitative research. Nordic and European experts performed a qualitative pilot study using anonymized cases of peripartum hysterectomy. It was feasible to anonymize narratives and we learned lessons in the form of themes for improved clinical care and future research. Therefore, we plan a Nordic anonymized review of the care of women who have undergone peripartum hysterectomy based on narratives. The qualitative outcomes of clinically relevant themes for quality improvement and research will add value to the quantitative analyses from the Nordic medical birth registries. In the longer term, we believe that qualitative audits should be an essential part of the process of continuing improvement in maternity care.

Prevalence and main outcomes of placenta accreta spectrum: a systematic review and meta-analysis.

OBJECTIVE DATA: The objective of this study was to evaluate the prevalence of placenta accreta spectrum in general population studies and the main maternal outcomes at delivery. STUDY: We searched PubMed, Google Scholar, clinicalTrials.gov, and MEDLINE between 1982 and 2018. Articles that provided data on the number of cases of placenta accreta spectrum per pregnancies, births, or deliveries in a defined population were used. STUDY APPRAISAL AND SYNTHESIS METHODS: Study characteristics were evaluated by 2 independent reviewers who used a predesigned protocol. Primary outcomes were the prevalence of placenta accreta spectrum and clinical diagnostic data at birth; the pathologic criteria were used to confirm the diagnosis. Secondary outcomes included cases that required transfusion, incidence of peripartum hysterectomy, and maternal mortality rates. Heterogeneity between studies was analyzed with the Cochran's Q-test and the I2 statistics. RESULTS: Of the 98 full-text studies that were identified, 29 articles met the defined criteria and included 22 retrospective and 7 prospective studies comprising 7001 cases of placenta accreta spectrum of 5,719,992 births. Prevalence rates ranged from 0.01-1.1% with an overall pooled prevalence of 0.17% (95% confidence interval, 0.14-0.19). Only 10 studies provided detailed histopathologic data. The pool prevalence for the adherent vs the invasive grades was 0.5 (95% confidence interval, 0.3-0.36) and 0.3 (95% confidence interval, 0.2-0.4) per 1000 births, respectively. The pooled incidence for peripartum hysterectomy was 52.2% (95% confidence interval, 38.3-66.4; I2=99.8%) and 46.9% (95 % confidence interval, 34-59.9; I2=98.8%) for hemorrhage that required transfusion. The pooled estimate of maternal death was 0.05% (95% confidence interval, 0.06-0.69; I2=73%). We found large amounts of heterogeneity between studies for all parameters and further quantification was limited because of methodologic inconsistencies between studies with regards to clinical criteria that were used for the diagnosis of the condition at birth and the histopathologic confirmation of the diagnosis and differential diagnosis between adherent and invasive accreta placentation. CONCLUSION: This meta-analysis indicated wide variation between studies for the prevalence rate of placenta accreta spectrum and for the different grades of accreta placentation that highlighted the need for consistency in definitions that are used to describe placenta accreta spectrum at birth and in the reporting of this increasing common obstetric complication.

The increasing role of a retained placenta in postpartum blood loss: a cohort study.

PURPOSE: To describe the association between quantity of blood loss, duration of the third stage of labour, retained placenta and other risk factors, and to describe the role of a retained placenta depending on the cutoff used to define postpartum haemorrhage. METHODS: Cohort study of all vaginal deliveries at two Danish maternity units between 1 January 2009 and 31 December 2013 (n = 43,357), univariate and multivariate linear regression statistical analyses. RESULTS: A retained placenta was shown to be a strong predictor of quantity of blood loss and duration of the third stage of labour a weak predictor of quantity of blood loss. The predictive power of the third stage of labour was further reduced in the multivariate analysis when including retained placenta in the model. There was an increase in the role of a retained placenta depending on the cutoff used to define postpartum haemorrhage, increasing from 12% in cases of blood loss ≥ 500 ml to 53% in cases of blood loss ≥ 2000 ml CONCLUSION: The predictive power of duration of the third stage of labour in regard to postpartum blood loss was diminished by the influence of a retained placenta. A retained placenta was, furthermore, present in the majority of most severe cases.

Intravenous iron isomaltoside treatment of women suffering from severe fatigue after postpartum hemorrhage.

Background and objectives: To explore if intravenous iron isomaltoside (Monofer®) leads to a better relief of fatigue than current treatment practice with oral iron in women suffering from severe fatigue after postpartum hemorrhage. Materials and methods: This is a subanalysis of a single-center, open-label, randomized controlled trial conducted in women suffering from postpartum hemorrhage. Participants were randomized 1:1 to 1200 mg iron isomaltoside or current treatment practice with oral iron. We measured fatigue by the Multidimensional Fatigue Inventory (MFI) and Edinburgh Postnatal Depression Scale, and determined hematological parameters. The subanalysis includes all participants with a high fatigue score (MFI physical fatigue score >15) at inclusion. The primary endpoint was aggregated change in physical fatigue score from inclusion to 12 weeks postpartum with a predefined minimum clinically relevant difference of 1.8. The trial is registered at ClinicalTrials.gov (identifier: NCT01895218). Results: A total of 85 women had a high fatigue score at inclusion. The aggregated change in physical fatigue score was -2.3 (confidence interval 95%: -3.3; -1.3) (p < .0001) in favor of iron isomaltoside. Significant differences in other fatigue and depression scores and hematological parameters were observed and all in favor of iron isomaltoside. There were no differences in side effects between the groups. Conclusions: In women suffering from severe fatigue after postpartum hemorrhage, a single dose of iron isomaltoside is associated with a statistically significant and clinically relevant reduction in aggregated physical fatigue within 12 weeks after delivery, when compared to current treatment practice with oral iron and with a similar safety profile.

Decline in severe spastic cerebral palsy at term in Denmark 1999-2007.

AIM: To analyse trends in prevalence and severity of cerebral palsy (CP) in Denmark in birth years 1999-2007 and compare with previous periods. METHOD: Data has been collected uniformly in the Danish cerebral palsy national register nationwide since 1995. Rates in the time periods 1999-2001, 2002-2004 and 2005-2007 covering 585,393 births were analysed by gestational age and subtypes. RESULTS: Total number of CP cases in the period was 1165. The overall prevalence of CP decreased significantly from 2.1 in 1999-2001 to 1.8 in 2005-2007 per 1000 livebirths (p = 0.022). The decline was only significant for children born at term (p = 0.007) but not for the preterm (p = 0.44). The decline in children born at term was based on a decrease in bilateral spastic CP (n = 117 in years 1999-2001 and n = 59 in 2005-2007). Multidisciplinary obstetric skills training with neonatal resuscitation in Denmark was initiated in 2003 and timely associated with the decrease. The prevalence of unilateral spastic CP the prevalence did not change, but in the two last time periods more children had a right-sided than left-sided unilateral spastic CP. CONCLUSION: The decline in rate of CP seen in 2005-2007 as compared to 1999-2001 was mainly based on fewer cases of severe spastic CP in term infants. We hypothesize that improved neonatal resuscitation in the delivery room may be partly responsible for the decrease. In premature children the decline was not significant in this time period, but has been dramatically decreasing in the years before the time period here analysed.

The Danish Medical Birth Register.

The Danish Medical Birth Register was established in 1973. It is a key component of the Danish health information system. The register enables monitoring of the health of pregnant women and their offspring, it provides data for quality assessment of the perinatal care in Denmark, and it is used extensively for research. The register underwent major changes in construction and content in 1997, and new variables have been added during the last 20 years. The aim was to provide an updated description of the register focusing on structure, content, and coverage since 1997. The register includes data on all births in Denmark and comprises primarily of data from the Danish National Patient Registry supplemented with forms on home deliveries and stillbirths. It contains information on maternal age provided by the Civil Registration System. Information on pre-pregnancy body mass index and smoking in first trimester is collected in early pregnancy (first antenatal visit). The individual-level data can be linked to other Danish health registers such as the National Patient Registry and the Danish National Prescription Registry. The register informs several other registers/databases such as the Danish Twin Registry and the Danish Fetal Medicine Database. Aggregated data can be publicly accessed on the Danish Health Data Authority web page ( www.esundhed.dk/sundhedsregistre/MFR ). Researchers can obtain access to individual-level pseudo-anonymised data via servers at Statistics Denmark and the Danish Health Data Authority.

Long-term anal incontinence after obstetric anal sphincter injury-does grade of tear matter?

BACKGROUND: Anal incontinence is a major concern following delivery with obstetric anal sphincter injury (OASIS), and has been related to the degree of sphincter tear. OBJECTIVE: The aims of this study were (1) to evaluate whether women with a fourth-degree OASIS in the first delivery have an increased risk of long-term anal and fecal incontinence after a second delivery, and (2) to assess the impact of mode of second delivery on anal incontinence and related symptoms in these patients. MATERIALS AND METHODS: We performed secondary analyses of a national questionnaire study in all Danish women with an OASIS in their first delivery and 1 subsequent delivery, both deliveries in 1997 to 2005. The questionnaires were sent a minimum of 5 years since the second delivery. In Denmark, women with anal incontinence after a delivery with OASIS are recommended elective cesarean deliveries in subsequent pregnancies. We performed uni- and multivariable logistic regression analyses to evaluate the outcomes. RESULTS: In total, 2008 patients had an OASIS, of whom 12.2% (n = 245) had a fourth-degree tear in the first delivery. The median follow-up time since the first delivery with OASIS was 11.6 years (IQR, 10.2-13.2 years) and since the second delivery 8.5 years (IQR, 7.1-10.1 years). Women with a fourth-degree sphincter injury in the first delivery were at higher risk for anal incontinence (58.8%, n = 144) as well as fecal incontinence (30.6%, n = 75) than patients with a third-degree injury in the first delivery (41.0%, n = 723, and 14.6%, n = 258, respectively). The differences between groups persisted after adjustment for important maternal, fetal, and obstetric characteristics (adjusted odds ratio [aOR], 2.14; 95% confidence interval [CI], 1.52-3.02; P < 0.001 for anal incontinence; and aOR, 2.49; 95% CI, 1.73-3.56; P < 0.001 for fecal incontinence). In subgroup analyses of patients with fourth-degree anal sphincter injury in the first delivery, the mode of second delivery was not associated with the risk of anal incontinence (aOR, 0.97; 95% CI, 0.41-1.84; P = 0.71) or fecal incontinence (aOR, 1.28; 95% CI, 0.65-2.52; P = 0.48). The effect of the mode of the second delivery did not differ between women with a fourth-degree OASIS and those with a third-degree injury with regard to both anal (P = 0.09) and fecal (P = 0.96) incontinence. CONCLUSION: After a second delivery, women with a fourth-degree OASIS in the first delivery have a higher risk of long-term anal and fecal incontinence than women with a third-degree sphincter injury. Adjusted odds of long-term anal and fecal incontinence did not differ significantly by mode of second delivery. Women with a fourth-degree OASIS should be informed about the increased risk of long-term anal incontinence and advised that subsequent elective cesarean delivery is not protective.

Failed manual removal of the placenta after vaginal delivery.

PURPOSE: A retained placenta after vaginal delivery where manual removal of placenta fails is a clinical challenge. We present six cases that illustrate the heterogeneity of the condition and discuss the etiology and terminology as well as the clinical management. METHODS: Members of the European Working group on Abnormally Invasive Placenta (EW-AIP) were invited to report all recent cases of retained placenta that were not antenatally suspected to be abnormally adherent or invasive, but could not be removed manually despite several attempts. RESULTS: The six cases from Denmark, The Netherlands and the UK provide examples of various treatment strategies such as ultrasound-guided vaginal removal, removal of the placenta through a hysterotomy and just leaving the placenta in situ. The placentas were all retained, but it was only possible to diagnose abnormal invasion in the one case, which had a histopathological diagnosis of increta. Based on these cases we present a flow chart to aid clinical management for future cases. CONCLUSION: We need properly defined stringent terminology for the different types of retained placenta, as well as improved tools to predict and diagnose both abnormally invasive and abnormally adherent placenta. Clinicians need to be aware of the options available to them when confronted by the rare case of a retained placenta that cannot be removed manually in a hemodynamically stable patient.