A retrospective study of pre-operative fasting times prior to elective or emergency cesarean birth in a large maternity hospital: Lessons to be learned to minimize the fasting time.

INTRODUCTION: When managing elective and emergency cesarean births in the same operating room, unpredictable variations in the start times of the cesareans can prolong fasting periods. METHODS: The fasting times were retrospectively analyzed on 279 consecutive cesarean births at Helsinki University Women's Hospital, Finland, during January-February 2023. The fasting times were compared between the urgency groups and for elective cesareans according to their scheduled order on the operation list. The primary outcome was the difference in the fasting times for food and drink, while the secondary outcome was fasting for both food >12 h and fluids >4 h. The fasting times were compared by one-way ANOVA and chi-squared test, respectively. Dichotomous data are presented as unadjusted odds ratios (OR with 95% CI). RESULTS: Increasing urgency was associated with shorter fasting times. Fasting times for elective cesareans increased with the scheduled order on the daily list. The mean fasting periods (SD) increased from 10.55 h (SD=1.57) to 14.75 h (SD=2.02) from the first to the third cesarean of the day (p<0.01). The unadjusted odds ratio (95% CI) for fasting of the scheduled cesareans to exceed 12 h for solid foods and 4 h for clear fluids was 6.53 (95% CI: 2.67-15.9, p<0.001), for the third and fourth cesareans compared to the first two cesareans of the day. CONCLUSIONS: When elective and emergency cesareans are performed by the same team, the woman undergoing the third elective surgery of the day should be advised to have breakfast before 5 a.m. at home. While waiting for the operation, a carbohydrate drink should be offered to limit the fast.

Risk factors for neonatal hypoxic ischemic encephalopathy and therapeutic hypothermia: a matched case-control study.

BACKGROUND: Peripartum asphyxia is one of the main causes of neonatal morbidity and mortality. In moderate and severe cases of asphyxia, a condition called hypoxic-ischemic encephalopathy (HIE) and associated permanent neurological morbidities may follow. Due to the multifactorial etiology of asphyxia, it may be difficult prevent, but in term neonates, therapeutic cooling can be used to prevent or reduce permanent brain damage. The aim of this study was to assess the significance of different antenatal and delivery related risk factors for moderate and severe HIE and the need for therapeutic hypothermia. METHODS: We conducted a retrospective matched case-control study in Helsinki University area hospitals during 2013-2017. Newborn singletons with moderate or severe HIE and the need for therapeutic hypothermia were included. They were identified from the hospital database using ICD-codes P91.00, P91.01 and P91.02. For every newborn with the need for therapeutic hypothermia the consecutive term singleton newborn matched by gender, fetal presentation, delivery hospital, and the mode of delivery was selected as a control. Odds ratios (OR) between obstetric and delivery risk factors and the development of HIE were calculated. RESULTS: Eighty-eight cases with matched controls met the inclusion criteria during the study period. Maternal and infant characteristics among cases and controls were similar, but smoking was more common among cases (aOR 1.46, CI 1.14-1.64, p = 0.003). The incidence of preeclampsia, diabetes and intrauterine growth restriction in groups was equal. Induction of labour (aOR 3.08, CI 1.18-8.05, p = 0.02) and obstetric emergencies (aOR 3.51, CI 1.28-9.60, p = 0.015) were more common in the case group. No difference was detected in the duration of the second stage of labour or the delivery analgesia. CONCLUSIONS: Smoking, induction of labour and any obstetric emergency, especially shoulder dystocia, increase the risk for HIE and need for therapeutic hypothermia. The decisions upon induction of labour need to be carefully weighed, since maternal smoking and obstetric emergencies can hardly be controlled by the clinician.

Pregnancy and delivery after lower body contouring surgery is safe for the mother and child.

BACKGROUND: Obesity in fertile age women has increased worldwide leading to increased bariatric procedures. Lower body contouring surgery (LBCS) is one of the most commonly performed esthetic operations, mainly owing to massive weight loss. However, there is a paucity of data regarding pregnancy and delivery after LBCS. In this study, we examined whether LBCS influences pregnancy or delivery and mother and baby outcome. METHODS: In this national registry-based study, we used data from the Finnish Institute of Health and Welfare and the Causes of Death registry. We included fertile age women, from 18 to 54 years who had LBCS with or without a bariatric procedure and who experienced pregnancy and delivery were compared to all deliveries in Finland during 1999- 2016. RESULTS: We identified 92 women who had LBCS before delivery. These 92 women had planned cesarean sections more often (P < .001) and preterm delivery was more common (P < .001). None of the mothers or babies died. Of the 92 women, 26 had a preceding bariatric procedure. The preceding bariatric procedures did not increase the risk for preterm delivery or low birth weight. The need for urgent or emergency sections was not increased. The heightened number of planned cesareans is caused by the different demographics of the study group, indicating that previous LBCS is not a contraindication for vaginal delivery. CONCLUSION: Pregnancy and delivery are safe for the mother and the baby after LBCS. The possible deviations from normal pregnancy and delivery should be discussed with fertile age women seeking LBCS.

High risk in the first-trimester combined screening: Long-term outcomes of the children.

OBJECTIVE: To bring new accuracy to the prognosis of outcomes of euploid fetuses with an extremely high risk in the first-trimester combined screening when compared to the low-risk group. STUDY DESIGN: The data included pregnancies with a trisomy 21 risk ≥ 1:50 in the combined first-trimester screening but normal fetal chromosomes. The control group had a risk value ≤ 1:300. Miscarriage, termination of pregnancy, stillbirth, premature delivery, and delivery of an unhealthy child were considered adverse outcomes. The impact of each component in the combined first-trimester screening was analyzed separately. Statistical comparisons were made by using the chi-square test, Fisher-Freeman-Halton test, Mann-Whitney test or t-test. RESULTS: The study comprised 483 women (161 cases and 322 controls). The mean follow-up time of children born alive was 61.4 months. An adverse outcome was detected in 11.8% of the cases and in 5.9% of the controls. After adjusting the values of mother´s age, parity, and smoking habit the odds ratio for an adverse outcome was 2.1 (95% CI: 1.0-4.5, p = 0.05) for cases. When evaluating the effect of 1 SD increase in MOM of PAPP-A or 1 SD decrease in MOM of NT or ß-hCG to any adverse outcome, 1 SD increase in PAPP-A MOM decreased the risk of adverse outcome by OR 0.48 (95% CI: 0.3 - 0.8, p = 0.05) while the others were not significant. CONCLUSION: Euploid fetuses with a high risk in the combined first-trimester screening have a twofold risk for adverse outcomes when compared to those with a low risk.

Most women living with HIV can deliver vaginally-National data from Finland 1993-2013.

INTRODUCTION: Vaginal delivery has been recommended for more than ten years for women living with HIV (WLWH) with good virological control. However, in Europe most WLWH still deliver by cesarean section (CS). Our aim was to assess the rate of vaginal delivery and the indications for CS in WLWH over 20 years in a setting of low overall CS rate. MATERIALS AND METHODS: This was a retrospective study of all WLWH delivering in Finland 1993-2013. We identified the women by combining national health registers and extracted data from patient files. RESULTS: The study comprised 212 women with 290 deliveries. Over 35% of the women delivered several children during the study years. During 2000-2013, with consistent viral load monitoring, 80.0% showed HIV viral loads <50 copies/mL in the last measurement preceding the delivery. Altogether 74.5% of all WLWH delivered vaginally and the rate of both elective CS and emergency CS was 12.8% each. For most CSs (63.5%) the indication was obstetrical, for 28.4% it was avoiding HIV transmission and for 0.7% it was mother's request. In hospitals with less than ten HIV-related deliveries during the study period, the rate of elective CS was higher than in more experienced hospitals (22.7% versus 10.6% [p = 0.024]). No perinatal HIV transmissions occurred. CONCLUSIONS: Most WLWH can achieve good virological control and deliver vaginally. This will help them to maintain their future child bearing potential and reduce CS-related morbidity.

False-negative results in routine combined first-trimester screening for down syndrome in Finland.

We analyzed the frequency and possible causes of false-negative (Fn) screening results in first-trimester combined Down syndrome screening in Finland. During the study period (May 1, 2002, to December 31, 2008), 76,949 voluntary women with singleton pregnancies participated in screening. Maternal age at screening, week of gestation, levels of pregnancy-associated plasma protein-A (PAPP-A), free ß-human chorionic gonadotropin (fß-hCG), and nuchal translucency (NT) measurement were compared and statistically analyzed between true-positive (Tp) and Fn cases. There were a total of 188 Down syndrome cases (1:409) in the screened population; 154 confirmed Tp and 34 Fn cases. Most Fn cases (n = 25) occurred at 12 + 0 to 13 + 6 weeks' gestation and only nine Fn cases presented between 10 and 11 weeks' gestation. According to the logistic regression analysis, the NT measurement was the most powerful discriminating factor in Fn screening results and accounted for 37.2% of Fn results. The second most important factor was fß-hCG, adding 14.0% to R(2), followed by PAPP-A, which contributed a further 14.3%. The chosen parameters explain 83.9% of Fn results, but 16.1% remain due to unknown factor(s). All investigated parameters contributed to Fn screening results, but fetal NT was the most discriminating factor leading to an Fn screening result.

More invasive procedures are done to detect each case of Down's syndrome in younger women.

OBJECTIVE: To evaluate the performance of first-trimester combined screening in 5-year periods according to maternal age in a low-risk population. DESIGN: A prospective study. SETTING: Multicenter study in Finland. POPULATION: A total of 76949 voluntary women with singleton pregnancies participated in first-trimester combined screening in public healthcare between 1 May 2002 and 31 December 2008. METHODS: The serum samples were analyzed using the PerkinElmer AutoDELFIA® time-resolved fluoroimmunoassay kit for the measurement of pregnancy-associated plasma protein-A and free beta-human chorionic gonadotropin. Nuchal translucency was measured by trained personnel (midwives or physicians) in a university or central hospital. MAIN OUTCOME MEASURES: Performance, detection rate, false positive rate and the number of invasive procedures needed to detect a single case of Down's syndrome were analyzed. RESULTS: There was a direct connection between maternal age and the prevalence of Down's syndrome with a low prevalence in young women being 1:1 193 in the 25-29 age group and 1:150 in the 35-39 age group. Consequently, for a fixed false positive rate of 5%, the number of invasive procedures needed to detect one case of Down's syndrome is higher in younger women to achieve the same detection rate. CONCLUSIONS: In combined first trimester screening the risk for Down's syndrome is individual, varying with maternal age. This should be taken into consideration when counseling women.