Prior placental bed disorders and later dementia: a retrospective Swedish register-based cohort study.

OBJECTIVE: To investigate the association between a history of placental bed disorders and later dementia. DESIGN: Retrospective population-based cohort study. SETTING: Sweden. SAMPLE: All women giving birth in Sweden between 1973 and 1993 (1 128 709). METHODS: Women with and without placental bed disorders (hypertensive disorders of pregnancy including pre-eclampsia, fetal growth restriction, spontaneous preterm labour and birth, preterm premature rupture of membranes, abruptio placenta, late miscarriages) and other pregnancy complications were identified by means of the Swedish Medical Birth Register. International classification of disease was used. Data were linked to other National Registers. Participants were followed up until 2013. The Cox proportional hazards model was used to calculate hazard ratios for women with and without pregnancy complications and were adjusted for possible confounders. MAIN OUTCOME MEASURES: Diagnosis of vascular dementia and non-vascular dementia. RESULTS: Adjusted for cardiovascular disease and socio-demographic factors, an increased risk of vascular dementia was shown in women with previous pregnancy-induced hypertension (Hazard ratio [HR] 1.88, 95% CI 1.32-2.69), pre-eclampsia (HR 1.63, 95% CI 1.23-2.16), spontaneous preterm labour and birth (HR 1.65, 95% CI 1.12-2.42) or preterm premature rupture of membranes (HR 1.60, 95% CI 1.08-2.37). No statistically significant increased risk was seen for other pregnancy complications or non-vascular dementia even though many of the point estimates indicated increased risks. CONCLUSIONS: Women with placental bed disorders have a higher risk for vascular disease. Mechanisms behind the abnormal placentation remain elusive, although maternal constitutional factors, abnormal implantation as well as impaired angiogenesis have been suggested. TWEETABLE ABSTRACT: Placental bed syndromes associated with vascular dementia even after adjusting for cardiovascular disease.

Pregnancy-associated plasma protein-A is positively correlated with first-trimester skin microvascular reactivity.

OBJECTIVE: To investigate the relationship between levels of circulating maternal pregnancy-associated plasma protein-A (PAPP-A) and first-trimester maternal vascular function. METHODS: This was a cross-sectional study of 53 healthy, non-smoking, nulliparous pregnant women in Stockholm, Sweden. PAPP-A levels and vascular function were assessed during gestational weeks 11-14. Forearm skin microcirculation was investigated by laser Doppler perfusion imaging during iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP) to assess endothelium-dependent and -independent microvascular vasodilatation, respectively. Microvascular endothelial function index was calculated as peak ACh/peak SNP. Endothelium-dependent and -independent vasodilatation in the brachial artery was evaluated, respectively, by postischemic hyperemia-induced flow-mediated vasodilatation (FMD) and by response to sublingual intake of glyceryl trinitrate (GTN). RESULTS: PAPP-A was correlated with skin microvascular endothelial function index (ß = 1.008 (95% CI, 0.34-1.68), r2  = 0.17, P = 0.004). PAPP-A also correlated inversely with FMD (ß = -0.052 (95% CI, -0.094 to -0.011), r2  = 0.13, P = 0.014) but did not relate to forearm endothelial function index (i.e. FMD/GTN). The results were retained in multivariate analyses including known confounding factors. CONCLUSIONS: First-trimester endothelium-dependent skin microvascular reactivity was positively related to PAPP-A levels. If confirmed, these novel findings suggest that first-trimester skin microvascular reactivity could be a useful early pregnancy marker of placental function. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Longitudinal study of vascular structure and function during normal pregnancy.

OBJECTIVE: To examine alterations in maternal vascular structure and function during normal pregnancy. METHODS: We assessed brachial and central blood pressure, pulse-wave velocity and augmentation index (by pulse-wave analysis and applanation tonometry), common carotid artery structure (by ultrasonography) and endothelial function in the brachial artery (by postischemic hyperemia-induced flow-mediated vasodilatation by glyceryl trinitrate) and in the forearm skin microcirculation (by laser Doppler perfusion imaging during iontophoretic administration of acetylcholine and sodium nitroprusside) in 52 healthy nulliparous women at 14, 24 and 34 weeks' gestation, and at 9 months postpartum. RESULTS: During pregnancy, brachial and central systolic and diastolic blood pressures initially decreased but subsequently increased (all P < 0.05). Flow-mediated vasodilatation in the brachial artery increased during early pregnancy (P < 0.05), whereas non-specific vasodilatation by glyceryl trinitrate decreased (P < 0.01), indicating improved endothelial function. Thus, endothelial function index (forearm blood flow/glyceryl trinitrate) increased during pregnancy (0.30 ± 0.18 in the non-pregnant state at 9 months postpartum and 0.51 ± 0.19, 0.61 ± 0.39 and 0.49 ± 0.30 in the first, second and third trimesters, respectively) (P < 0.001). Endothelium-dependent skin microvascular reactivity to acetylcholine also increased (P < 0.01). Carotid-femoral pulse-wave velocity decreased during pregnancy (5.88 ± 0.91 m/s in the non-pregnant state and 5.55 ± 0.67, 5.12 ± 0.66 and 5.62 ± 0.74 m/s in the first, second and third trimesters, respectively) (P < 0.001). CONCLUSION: During normal pregnancy, the blood volume expansion necessary for sufficient fetal growth is accommodated by early and marked changes in the matvascular system. This seems to be dependent on normal adaptive endothelial and vascular function. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Fetal growth is associated with first-trimester maternal vascular function.

OBJECTIVE: To investigate the relationship between maternal endothelial function in the first trimester, assessed in both the brachial artery and the forearm skin microcirculation, and fetal growth. METHODS: Vascular function was assessed in 56 pregnant women during gestational weeks 11-14. Vascular reactivity in the brachial artery was evaluated by postischemic hyperemia-induced flow-mediated vasodilatation (FMD) and by vasodilatation following administration of sublingual glyceryl trinitrate (GTN). Forearm skin microcirculation was investigated by laser Doppler perfusion imaging during iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP) to assess endothelium-dependent and -independent microvascular vasodilatation, respectively. Fetal growth was measured at study inclusion and birth-weight centile was calculated after delivery. RESULTS: FMD and GTN-induced vasodilatation were both associated with birth-weight centile. On multivariate analysis (adjusted for brachial artery diameter at rest, blood pressure, maternal age and heart rate), for FMD ß = 1.7 (95% CI, 0.06-3.34), r2 = 0.26 and P = 0.042, and for GTN-induced vasodilatation ß = 2.6 (95% CI, 0.44-4.68), r2 = 0.15 and P = 0.02. Endothelium-dependent and -independent microvascular reactivity were also associated with birth-weight centile: for ACh ß = 7.82 (95% CI, 1.81-13.83), r2 = 0.12 and P = 0.029, and for SNP ß = 6.27 (95% CI, 1.20-11.34), r2 = 0.11 and P = 0.016. CONCLUSION: First-trimester maternal vascular dilatation capacity (rather than endothelial function alone) is associated with fetal growth. These findings were consistent in both the brachial artery and the forearm skin microcirculation. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Psychiatric illness in women requesting caesarean section.

OBJECTIVE: To compare psychiatric in- and outpatient care during the 5 years before first delivery in primiparae delivered by caesarean section on maternal request with all other primiparae women who had given birth during the same time period. DESIGN: Prospective, population-based register study. SETTING: Sweden. SAMPLE: Women giving birth for the first time between 2002 and 2004 (n = 64 834). METHODS: Women giving birth by caesarean section on maternal request (n = 1009) were compared with all other women giving birth (n = 63 825). The exposure of interest was any psychiatric diagnosis according to the International Statistical Classification of Diseases and Related Health Problems (ninth revision, ICD-9, 290-319; tenth revision, ICD-10, F00-F99) in The Swedish national patient register during the 5 years before first delivery. MAIN OUTCOME MEASURES: Psychiatric diagnoses and delivery data. RESULTS: The burden of psychiatric illnesses was significantly higher in women giving birth by caesarean section on maternal request (10 versus 3.5%, P < 0.001). The most common diagnoses were 'Neurotic disorders, stress-related disorders and somatoform disorders' (5.9%, aOR 3.1, 95% CI 1.1-2.9), and 'Mood disorders' (3.4%, aOR 2.4, 95% CI 1.7-3.6). The adjusted odds ratio for caesarean section on maternal request was 2.5 (95% CI 2.0-3.2) for any psychiatric disorder. Women giving birth by caesarean section on maternal request were older, used tobacco more often, had a lower educational level, higher body mass index, were more often married, unemployed, and their parents were more often born outside of Scandinavia (P < 0.05). CONCLUSIONS: Women giving birth by caesarean section on maternal request more often have a severe psychiatric disease burden. This finding points to the need for psychological support for these women as well as the need to screen and treat psychiatric illness in pregnant women.

Caesarean section and risk for endometriosis: a prospective cohort study of Swedish registries.

OBJECTIVE: To investigate the association between caesarean section and later endometriosis. DESIGN: A prospective cohort study. SETTING: The Swedish Patient Register (PAR) and the Swedish Medical Birth Registry (MBR). SAMPLE: Women who were delivered in Sweden between 1986 and 2004. METHODS: Women with the diagnosis of endometriosis, defined as codes 617 (International Classification of Diseases, ninth revision, ICD-9) or N80 (ICD-10), were retrieved from the PAR. Obstetric outcome was assessed through linkage with the MBR. Out of 709,090 women, 3110 were treated as inpatients with a first diagnosis of endometriosis after their first delivery. Women with a diagnosis of endometriosis before their first delivery were excluded. Cox analyses were performed to obtain hazard ratios for endometriosis and adjusted for maternal age at first delivery, body mass index, maternal smoking, and years of involuntary childlessness at study entry. Kaplan-Meier estimates were performed to calculate the risk according to time elapsed. MAIN OUTCOME: In-hospital diagnosis of endometriosis. RESULTS: The Cox analyses yielded a hazard ratio of 1.8 (95% CI 1.7-1.9) for endometriosis in women who had had a previous caesarean section compared with women with vaginal deliveries only. The risk of endometriosis increased over time: one additional case of endometriosis was found for every 325 women undergoing caesarean section within 10 years. No increase in risk could be seen after two caesarean deliveries. The risk of caesarean scar endometrioma was 0.1%. CONCLUSION: In addition to the recognised risk of scar endometrioma, we found an association between caesarean section and general pelvic endometriosis. Further studies are needed to confirm our findings.

Large fetal size in early pregnancy associated with macrosomia.

OBJECTIVE: To assess if fetal size at the time of ultrasound dating examination is associated with the risk of macrosomia and complications associated with macrosomia. METHODS: This was a retrospective cohort study of 19 377 singleton pregnancies dated in gestational weeks 16-20 during the period 1998-2004 at Danderyd Hospital, Stockholm, Sweden. Obstetric outcome was assessed through linkage to the Swedish Medical Birth Register. RESULTS: When fetuses were > or = 7 days larger than expected at dating, compared with the expected size according to last menstrual period, there was a 59% increase in the risk of birth weight > or = 4500 g and a 145% increase in the risk of birth weight > or = 5000 g (odds ratio (OR), 1.59; 95% CI, 1.12-2.24 and OR, 2.45; 95% CI, 1.22-4.90, respectively). For a birth weight of > or = 4000 g the risk estimate was 1.19 (95% CI, 0.96-1.47). CONCLUSION: Fetuses that are larger than expected in the second trimester have an increased risk of macrosomia. This emphasizes that fetal size in early pregnancy is not only a function of gestational duration, but also of fetal growth. However, only a limited proportion of all infants born macrosomic can be identified as such at the time of ultrasound dating.

Expectation and experiences of childbirth in primiparae with caesarean section.

OBJECTIVE: The aim of this study was to examine the expectations and experiences in women undergoing a caesarean section on maternal request and compare these with women undergoing caesarean section with breech presentation as the indication and women who intended to have vaginal delivery acting as a control group. A second aim was to study whether assisted delivery and emergency caesarean section in the control group affected the birth experience. DESIGN: A prospective group-comparison cohort study. SETTING: Danderyd Hospital, Stockholm, Sweden. SAMPLE: First-time mothers (n= 496) were recruited to the study in week 37-39 of gestation and follow up was carried out 3 months after delivery. Comparisons were made between 'caesarean section on maternal request', 'caesarean section due to breech presentation' and 'controls planning a vaginal delivery'. METHODS: The instrument used was the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ). MAIN OUTCOME MEASURES: Expectations prior to delivery and experiences at 3 months after birth. RESULTS: Mothers requesting a caesarean section had more negative expectations of a vaginal delivery (P < 0.001) and 43.4% in this group showed a clinically significant fear of delivery. Mothers in the two groups expecting a vaginal delivery, but having an emergency caesarean section or an assisted vaginal delivery had more negative experiences of childbirth (P < 0.001). CONCLUSIONS: Women requesting caesarean section did not always suffer from clinically significant fear of childbirth. The finding that women subjected to complicated deliveries had a negative birth experience emphasises the importance of postnatal support.

Expected day of delivery from ultrasound dating versus last menstrual period--obstetric outcome when dates mismatch.

OBJECTIVE: To analyse the association between fetal size at time of dating ultrasound and risk for preterm delivery and small-for-gestational-age (SGA) birth and to evaluate if timing of ultrasound, that is before 14 weeks of gestation or after 16 weeks affects this association. DESIGN: Retrospective cohort study. SETTING: Ultrasound departments of Ultragyn, Stockholm, Sweden. POPULATION: A total of 28,776 singleton pregnancies dated between 1998 and 2004. METHODS: Obstetric outcome was assessed through linkage of the cohort to the Swedish Medical Birth Register. MAIN OUTCOME MEASURES: Risks of preterm delivery, low birthweight for gestational age, pre-eclampsia, asphyxia, respiratory distress, instrumental delivery, caesarean section, and postterm birth were calculated for the groups dated early and late. RESULTS: When the expected date of delivery was postponed after ultrasound dating by 7 days or more, there was an increased risk for preterm delivery and pre-eclampsia in the late dating group (OR 1.49, 95% CI 1.27-1.73 and OR 1.27, 95% CI 1.02-1.60, respectively) but not in the early dating group. In both dating groups, there was an increased risk for SGA birth (OR 1.77, 95% CI 1.13-2.78 and OR 2.09, 95% CI 1.59-2.73, respectively) There was no increased risk for any of the other diagnoses. CONCLUSION: Our study gives further support to the notion that intrauterine growth restriction may be present as early as the first trimester. Accordingly, our study also suggests that surveillance of pregnancies with postponed estimated date of delivery may provide means for increased detection of fetal growth restriction.

Diagnosis and follow-up of simple ovarian cysts detected by ultrasound in postmenopausal women.

OBJECTIVE: To determine the malignancy rate in ultrasound-diagnosed, anechoic, small, simple ovarian cysts in postmenopausal women, and to investigate the natural history of these cysts by ultrasound follow-up. METHODS: Eighty-three postmenopausal women with small, completely anechoic, thin-walled ovarian cysts (less than 5 cm, mean of orthogonal diameters) were diagnosed at our ultrasound unit during the period 1983-1992. Forty-three underwent surgery; the remaining 40 were offered follow-up ultrasonography as part of the present study, and, of them, five died, two were unavailable because of intercurrent disease, and one moved abroad, leaving 32 to be included in our study. RESULTS: There were no cases of ovarian cancer in the surgery group. In the nonsurgery (follow-up) group, the time since detection of the lesion ranged from 1-9 years. On follow-up ultrasonography, 12 of the 32 cysts had disappeared and only one had increased in size. According to histopathology records, no ovarian cancer was diagnosed in any of the seven cases in which the patient was not available for reexamination by ultrasound. CONCLUSION: Nonpalpable ovarian cysts are commonly detected by ultrasound in asymptomatic women, but the risk of malignancy appears to be very low. We recommend ultrasound follow-up of stationary lesions and that surgery be confined to symptomatic cases or those in which there is a family history of ovarian, breast, or colon cancer.

Ultrasonic thickness of the endometrium correlated to body weight in asymptomatic postmenopausal women.

OBJECTIVE: To estimate the prevalence and significance of an endometrial thickness of 5 mm or greater measured by ultrasound in postmenopausal women without vaginal bleeding. METHODS: Three hundred asymptomatic postmenopausal women scheduled for cervical cancer screening were also examined by transvaginal ultrasound. When the endometrium was 5 mm thick or greater, ultrasound was repeated every third month. Curettage was performed at the end of the study or if endometrial growth or vaginal bleeding occurred. RESULTS: The mean (+/- standard deviation) endometrial thickness was 2.3 +/- 1.8 mm (range 0-10). In women with endometrium measuring less than 5 mm, the endometrial thickness correlated to body weight. The endometrium measured 5 mm or more in 22 women, who were followed with ultrasound for 1-25 months. Body weight and body mass index (BMI) were higher in women with a thick endometrium. Serum levels of estrone, estradiol, FSH, and LH differed from those in women with normal ultrasound findings. Curettage revealed no case of malignancy. Fourteen cases of benign ovarian lesions were also diagnosed, and only one case of pelvic fluid was found (in a patient with liver cirrhosis). CONCLUSION: The prevalence of a thick endometrium was high in asymptomatic women, and endometrial thickness correlated with BMI.

Ultrasound examination for detection of ovarian carcinoma in risk groups.

Ovarian ultrasound scanning was carried out as an adjunct to pelvic examination in 801 women between 40-70 years of age presenting at the outpatient Department of Obstetrics and Gynecology, University Hospital, Lund, Sweden for a variety of gynecologic complaints. All belonged to a high-risk category for ovarian carcinoma because of nulliparity; family history of ovarian, breast, or endometrial carcinoma; previous cancer; or unspecified abdominal complaints. Of 638 patients with normal scans, findings at pelvic examination had been abnormal in 51 cases, and all were normal at subsequent clinical follow-up. Among 163 patients with abnormal ultrasound scans, one case of borderline ovarian tumor and two cases of endometrial cancer were found for which the pelvic examination had been considered normal. Clinical symptoms probably would have led to detection within a short time in these cases anyway, even if ultrasound had not been performed. Based on the findings in this study and the previous experience with gynecologic ultrasound in several thousand patients, it would not seem that ultrasound has a role in screening for ovarian carcinoma.

Fluid characteristics of benign ovarian cysts: correlation with recurrence after puncture.

OBJECTIVE: To determine whether concentrations of gonadal steroids and fibrinolytic indices in fluid from benign ovarian cysts can discriminate between functional and neoplastic cysts and predict recurrence after ultrasound-guided puncture. METHODS: Concentrations of gonadal steroids and components of the plasminogen-activating system were measured in cyst fluid obtained at ultrasound-guided puncture of 96 ovarian cysts and were related to subsequent cyst recurrence. In 83 patients who had surgery for benign ovarian cysts, components of the plasminogen-activating system in the cyst fluid were correlated with the histopathologic diagnosis. RESULTS: Higher levels of plasminogen activators and lower levels of inhibitors were found in those 54 cysts that recurred after puncture and in cysts with low levels (below 2000 pmol/L) of estradiol (E2). This enzyme-inhibitor balance resulted in high fibrinolytic activity. In contrast, cysts with high E2 levels (above 2000 pmol/L) had lower levels of activators, higher levels of inhibitors, and virtually no fibrinolytic activity. A high E2 concentration in cyst fluid was the single best predictor of no recurrence after puncture. Sixteen of 18 cysts in postmenopausal women recurred, and all had low levels of E2. However, an index based on cyst fluid volume and concentrations of E2 and urokinase predicted recurrence even better. A high concentration of urokinase in the fluid correlated with neoplastic histology of the cysts obtained at laparotomy. CONCLUSION: The fluid content of ovarian steroids and plasminogen activators and inhibitors is related to histopathology and recurrence after puncture of benign ovarian cysts. Puncture and assay of these components may minimize surgery on functional cysts.

Disaccordance between estimation of endometrial thickness as measured by transvaginal ultrasound compared with hysteroscopy and directed biopsy in breast cancer patients treated with tamoxifen.

OBJECTIVE: To estimate endometrial thickness by transvaginal ultrasound technique (TVU) in patients treated with tamoxifen; and to compare the results with hysteroscopy and directed biopsy, and to relate the findings to curettage material. METHODS: Fifty-four women, over 50 years of age at the time of their primary breast cancer operation and scheduled for adjuvant treatment of tamoxifen, were investigated. If the endometrium measured 8 mm or more (35 patients) hysteroscopy and directed biopsy was performed. RESULTS: In the 35 patients, hysteroscopy and curretage revealed polyps in 18 cases (51.4%), proliferation in 1 case (2.9%) and atrophy in 16 cases (45.7%). In 54.3% (19 cases) of the patients the histopathological finding was a polyp or benign proliferation of the endometrium in agreement with the thickened endometrium seen with TVU. In the remaining 45.7% (16 cases) of the patients a thickened endometrium by transvaginal ultrasound was false positive as the hysteroscopic and subsequent histopathological diagnosis only showed atrofia of the uterine endometrium. CONCLUSIONS: In almost half of the patients the TVU gave a misleading picture concerning the condition of the endometrium. Changes in the myometrium and related connective tissue could be misinterpreted by the ultrasound technique as changes in the endometrium. These results may confirm the theory that stimulation and changes by antiestrogenic treatment of the uterine tissue is not only restricted to the endometrium. In patients with thickened endometrium measured by TVU, a dilatation and curettage is not sufficient, as TVU has not the ability to differentiate between endometrial polyps and myometrial changes. A hysteroscopy and directed biopsy could therefore be performed.

Endometrial thickness and ovarian cysts as measured by ultrasound in asymptomatic postmenopausal breast cancer patients on various adjuvant treatments including tamoxifen.

Endometrial thickness as measured by ultrasound during tamoxifen treatment has previously been reported. However, there has not been any study investigating endometrial thickness before treatment and following it at regular intervals during treatment. 90 patients with breast cancer without any gynecological symptoms were followed (aged more than 50 years at the operation of their breast cancer). They were investigated by vaginal ultrasound and a common clinical investigation at our out-care patient department. Adjuvant breast cancer therapy consisted of tamoxifen, tamoxifen after radiotherapy and/or in a few cases cytostatics, cytostatics with or without the addition of radiotherapy, radiotherapy or no further therapy. Patients with receptor positive tumours were given tamoxifen. Their endometrium was already thicker before the start of adjuvant treatment as measured by ultrasound. After 3 months and 12 months we found the endometrium to be significantly thicker in those treated with tamoxifen compared to other treatment groups. After 12 months of tamoxifen treatment 22/32 women had an endometrial thickness of 5 mm or more. The frequency of ovarian cysts also seemed to be affected by therapy. In patients treated with tamoxifen alone or in combination, the frequency of cysts was 5/35 before treatment, 6/37 after 3 months, and 0/32 after one year. The corresponding frequencies for those not treated with tamoxifen were 2/20, 3/11 and 3/23 respectively.

Histopathologic findings in thickened endometria, as measured by ultrasound in asymptomatic, postmenopausal breast cancer patients on various adjuvant treatment including tamoxifen.

Pallents with breast cancer exhibit an increased risk of developing cancer from other organs, a risk that might increase due to tamoxifen treatment. This drug has been found to cause activation of oestrogen receptors, leading to oestrogenic effects on the postmenopausal endometrium. We report follow-up of 94 patients with breast cancer without initial symptoms aged more than 50 years at the time of operation. They were followed-up with vaginal ultrasound at regular intervals and endometrial sampling was performed according to treatment after surgery: tamoxifen, tamoxifen in combination with other regimes and without tamoxifen treatment. A large proportion were investigated prior to treatment. We identified endometrial carcinoma, metastasis of breast carcinoma and histopathological changes in 17/67 (25%) of the patients treated with tamoxifen compared to 1/32 in those not treated with tamoxifen.

Changes in ultrasound appearance of the internal female genital organs during treatment for eating disorders.

OBJECTIVE: To confirm that changes of the internal female genital organs in patients with eating disorders can be detected with ultrasound and that successive normalization can be followed during treatment. STUDY DESIGN: Thirty-five women with the diagnoses of eating disorders were examined with ultrasound while undergoing psychiatric treatment. The endometrial thickness and ovarian volume were measured. The sonographic picture of the ovaries was classified in four classes. RESULTS: Bulimics had changes of their ovaries in spite being of normal weight. After psychiatric treatment and a normal diet, the ovaries and the bleeding pattern normalized without a change in body weight. In anorectics, undetectable ovaries or ovaries without follicles were associated with low body mass index (BMI), but multifollicular ovaries or presence of a dominant follicle and ovarian volume had no clear relation to BMI. The endometrial thickness correlated with BMI. CONCLUSION: Ovarian morphology appeared more important than ovarian size. Changes of the ovaries appeared more related to eating patterns than to BMI. Eating disorders should be considered in women with bleeding disorders. Ultrasound examination can contribute to the differential diagnosis.

[Gynecological ultrasound is of uncertain value in screening]. / Gynekologiskt ultraljud av oklart värde vid screening.

In the past ten years, gynecological ultrasonography has proliferated rapidly, and is by some gynecologists considered an integral part of the gynecological exam. Abnormalities are detected in a asymptomatic women at a high rate, resulting in a number of surgical interventions due to suspected malignancy. Present evidence is insufficient to determine the medical and economical value, if any, of surgical removal. Such intervention may in fact be as detrimental as leaving an abnormality in place. Gynecological ultrasonography should therefore be performed on strict medical indications. Proper training of operators is also vital.

Starting time for induction of labor and the risk for night-time delivery.

OBJECTIVE: To analyze if starting time for labor induction affected the risk of night-time delivery, and to evaluate to what extent the risk was influenced by Bishop score at start of induction, mode of induction, and parity. METHOD: A retrospective cohort study of women who delivered at Danderyd Hospital, Stockholm, Sweden, 2002-2006, comprising 1940 women induced by Dinoprostone (PGE(2)) or transcervical balloon catheter (BARD). Risks for night-time delivery were calculated as absolute risk and Odds Ratios by unconditional logistic regression using induction of labor in the morning as reference. RESULTS: For nulliparae with Bishop score 0-3 induced by BARD, odds ratios for night-time delivery were 0.42 (95% C.I. 0.19-0.93) and 0.09 (95% C.I. 0.02-0.47) when inductions started in the afternoon and evening, respectively, compared to inductions starting in the morning For multiparae, however, the risk of night-time delivery was highest if induction started in the evening. Compared to inductions started in the morning, odds ratios for night-time delivery were 3.53 (95% C.I. 2.57-4.83) and 8.49 (95% C.I. 4.45-16.19) for induction starting in the afternoon and evening, respectively. CONCLUSION: Starting time of labor induction affects the risk of giving birth at night. For nulliparae induced by BARD, starting the induction in the evening instead of during the day may reduce the number of night-time deliveries substantially. For multiparae, however, our data suggest that induction of labor should take place in the morning.