Symphysis-fundus height measurement to predict small-for-gestational-age status at birth: a systematic review.

BACKGROUND: Fetal growth restriction is among the most common and complex problems in modern obstetrics. Symphysis-fundus (SF) height measurement is a non-invasive test that may help determine which women are at risk. This study is a systematic review of the literature on the accuracy of SF height measurement for the prediction of small-for-gestational-age (SGA) status at birth in unselected and low-risk pregnancies. METHODS: The Medline, Embase, Cinahl, SweMed, and Cochrane Library databases were searched with no limitation on publication date (through September 2014), which returned 722 citations. Two reviewers then developed a short list of 51 publications of possible relevance and assessed them using the following inclusion criteria: cohort study of test accuracy performed in a routine prenatal care setting; SF height measurement for all participants; classification of SGA, defined as birth weight (BW) < 10th, 5th, or 3rd percentile or ≥ one or two standard deviations below the mean; study conducted in Northern, Western, or Central Europe; USA; Canada; Australia; or New Zealand; and sufficient data for 2 × 2 table construction. Quality of the included studies was assessed in duplicate using criteria suggested by the Cochrane Collaboration. Review Manager 5.3 software was used to analyze the data, including plotting of summary receiver operating curve spaces. RESULTS: Eight studies were included in the final dataset and seven were included in summary analyses. The sensitivity of SF height measurement for SGA (BW < 10(th) percentile) prediction ranged from 0.27 to 0.76 and specificity ranged from 0.79 to 0.92. Positive and negative likelihood ratios ranged from 1.91 to 9.09 and from 0.29 to 0.83, respectively. CONCLUSIONS: SF height can serve as a clinical indicator along with other clinical findings, information about medical conditions, and previous obstetric history. However, SF height has high false-negative rates for SGA. Clinicians must understand the limitations of this test. The protocol has been registered in the international prospective register of systematic reviews, PROSPERO (Registration No. CRD42014008928, http://www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD42014008928 ).

Claims for compensation after alleged birth asphyxia: a nationwide study covering 15 years.

OBJECTIVE: To analyze compensation claims with neurological sequela or death following alleged birth asphyxia. DESIGN: A cohort study. SETTING: A nationwide study in Norway. SAMPLE: All claims made to The Norwegian System of Compensation to Patients (NPE) concerning sequela related to alleged birth asphyxia, between 1994 and 2008. A total of 315 claims of which 161 were awarded compensation. METHODS: Examination of hospital records, experts' assessments and the decisions made by the NPE, the appeal body and courts of law. MAIN OUTCOME MEASURES: Characteristics of deliveries resulting in intrapartum asphyxia and causes of substandard care categorized in eight groups. RESULTS: In the 161 compensated cases, 107 children survived (96 with neurological sequela), and 54 children died. Human error was a frequent reason of substandard care, seen as inadequate fetal monitoring (50%), lack of clinical knowledge and skills (14%), noncompliance with clinical guidelines (11%), failure in referral for senior medical help (10%) and error in drug administration (4%). System errors were registered in only 3%, seen as poor organization of the department, lack of guidelines and time conflicts. The health personnel held responsible for substandard care was an obstetrician in 49% and a midwife in 46%. CONCLUSIONS: Substandard care is common in birth asphyxia, and human error is the cause in most cases. Inadequate fetal monitoring and lack of clinical knowledge and skills are the most frequent reasons for compensation after birth asphyxia.

A nationwide descriptive study of obstetric claims for compensation in Norway.

OBJECTIVE: To describe causes of substandard care in obstetric compensation claims. DESIGN AND SETTING: A nationwide descriptive study in Norway. POPULATION: All obstetric patients who believed themselves inflicted with injuries by the Health Service and applying for compensation. METHODS: Data were collected from 871 claims to The Norwegian System of Compensation to Patients during 1994-2008, of which 278 were awarded compensation. MAIN OUTCOME MEASURES: Type of injury and cause of substandard care. RESULTS: Of 871 cases, 278 (31.9%) resulted in compensation. Of those, asphyxia was the most common type of injury to the child (83.4%). Anal sphincter tear (29.9%) and infection (23.0%) were the most common types of injury to the mother. Human error, both by midwives (37.1% of all cases given compensation) and obstetricians (51.2%), was an important contributing factor in inadequate obstetric care. Neglecting signs of fetal distress (28.1%), more competent health workers not being called when appropriate (26.3%) and inadequate fetal monitoring (17.3%) were often observed. System errors such as time conflicts, neglecting written guidelines and poor organization of the department were infrequent causes of injury (8.3%). CONCLUSIONS: Fetal asphyxia is the most common reason for compensation, resulting in large financial expenses to society. Human error contributes to inadequate health care in 92% of obstetric compensation claims, although underlying system errors may also be present.

Maternal left ventricular and endothelial functions in preeclampsia.

OBJECTIVE: To compare maternal left ventricular and endothelial functions in preeclampsia and normal pregnancy, during pregnancy and after delivery. DESIGN: Observational study with follow-up. SETTING: University hospital and midwife-led antenatal care center. SAMPLES: Twenty untreated women with preeclampsia and 20 women with normal pregnancy, matched for gestational age and parity. METHODS: The women were examined during pregnancy and three months after delivery. Left ventricular function was assessed by echocardiography, including tissue-Doppler imaging. Endothelial function was assessed by measuring flow-mediated dilation of the brachial artery. MAIN OUTCOME MEASURES: Early diastolic mitral annular tissue velocity, "e", peak systolic tissue velocity, "S", and flow-mediated dilation. RESULTS: The diastolic function was reduced in preeclampsia, with lower "e", and there was a higher ratio of early diastolic mitral inflow velocity and early diastolic mitral annular velocity, "E/e". Early diastolic mitral inflow deceleration time and isovolumetric relaxation time were similar between the groups, suggesting pseudonormalization and increased filling pressures in preeclampsia. "S" was lower in the preeclampsia group during pregnancy. Both diastolic and systolic left ventricular functions normalized postpartum. The flow-mediated dilation was impaired in the preeclampsia group both during pregnancy and three months after delivery. CONCLUSIONS: The maternal left ventricular function was impaired during preeclampsia but had normalized three months after delivery. The endothelial function, measured by flow-mediated dilation, was impaired in the preeclampsia group as compared with the normal pregnancy group both during pregnancy and three months after delivery.

Restless legs syndrome in pregnancy is a frequent disorder with a good prognosis.

The aim of this study was to assess the prevalence of restless legs syndrome in pregnancy. We distributed a questionnaire to 541 consecutive postpartum patients and received answers from 251 (46%) women. Of the participants, 34% reported restless legs syndrome in pregnancy. In 97% of the women in whom restless legs syndrome had started during the pregnancy, the symptoms disappeared within two to three days after delivery. There was no correlation between pregnancy-related restless legs syndrome and low hemoglobin levels in the first trimester, and the incidence of restless legs syndrome was not affected by use of iron supplementation. We conclude that in our population, restless legs syndrome in pregnancy is both frequent and transient, occurring in approximately one in three pregnancies and typically resolving within a few days after delivery.

Sex ratio and pregnancy complications according to mode of conception in women with polycystic ovary syndrome.

OBJECTIVE: To investigate pregnancy complications and offspring sex ratio according to mode of conception in women with polycystic ovary syndrome (PCOS). DESIGN: Retrospective, descriptive study. SETTING: Tertiary, university hospital. POPULATION: A total of 176 women with PCOS diagnosed according to the Rotterdam criteria. METHODS: Women with PCOS who have participated in one or more clinical studies were invited to answer a questionnaire on the mode of conception, pregnancy complications, gestational length and offspring gender. A total of 139 women responded. Data were quality checked against hospital files. MAIN OUTCOME MEASURES: Fertility, mode of conception, offspring gender and pregnancy complications. RESULTS: More than half (54%) of the singleton pregnancies were conceived spontaneously. More complications were seen in pregnancies achieved while using metformin than without (p = 0.02). Compared to spontaneous conception, more boys than girls were born in singleton pregnancies after in vitro fertilization/intracytoplasmatic sperm injection treatment (p = 0.004). CONCLUSIONS: In women with PCOS the mode of conception may influence both the rate of pregnancy complications and the offspring sex ratio.

Obstetric brachial plexus palsy: a birth injury not explained by the known risk factors.

OBJECTIVE: To determine the incidence and prognosis of obstetric brachial plexus injuries and analyze associated risk factors. DESIGN: Analysis of prospectively collected information comprising all births from 1991 to 2000, with complete follow-up of affected children. Setting. St Olav's University Hospital, a tertiary care hospital in the middle part of Norway. POPULATION: Thirty thousand five hundred and seventy-four children; all were examined within 24 hours of birth and 91 were diagnosed with brachial plexus injury. METHODS: We reviewed the hospital records and analyzed the data submitted from our hospital to the Medical Birth Register of Norway. RESULT: Risk factors are shoulder dystocia, macrosomy, diabetes, vacuum extraction and forceps delivery. The predictive power of these variables is poor. Almost half of the plexus injuries followed spontaneous vaginal deliveries with second stage of 30 minutes or less. Two newborns were delivered by cesarean section and two were vaginal breech deliveries. In 15 children (0.5/1,000) a permanent plexus injury has been diagnosed. Compared with transient plexus impairment, risk factors for a permanent injury were high maternal body mass index, shoulder dystocia, fractured humerus and fetal asphyxia. Fracture of the clavicle was significantly more frequent when the injury was transient, possibly reflecting a protective effect. CONCLUSION: The incidence of obstetric brachial plexus injury is 0.3% and the recovery rate is 84%, resulting in 0.5 permanent injuries per 1,000 births. Plexus injury is not well predicted by known risk factors. Other etiological factors should be sought.

A 12-week randomised study comparing intravenous iron sucrose versus oral ferrous sulphate for treatment of postpartum anemia.

OBJECTIVE: To analyze the effect of intravenous ferrous sucrose compared with oral ferrous sulphate on hematological parameters and quality of life in women with postpartum anemia. DESIGN: Open randomised controlled trial. SETTING: Multicentre study comprising five obstetrical departments in Norway. POPULATION: Hundred and twenty-eight postpartum women with hemorrhagic anemia (Hb between 6.5 g/100 ml and 8.5 g/100 ml). The intervention group (59 women) received 600 mg iron sucrose intravenously followed by 200 mg iron sulphate daily from week 5. The control group (70 women) were given 200 mg iron sulphate daily. METHODS: Randomisation and start of treatment occurred within 48 hours of the delivery. Participants were followed up at 4, 8 and 12 weeks. MAIN OUTCOME MEASURES: Hemoglobin, ferritin and quality of life assessed with the Medical Outcomes Study Short Form 36 (SF-36) and the Fatigue Scale. RESULTS: After 4 weeks the mean hemoglobin values in both groups were similar (11.9 g/100ml vs. 12.3g/100ml, p=0.89). The mean serum ferritin value after 4 weeks was significantly higher in the intervention group with 13.7 microg/L vs. 4.2 microg/L in the control group (p<0.001). At 8 and 12 weeks the hematological parameters were similar. The total fatigue score was significantly improved in the intervention group at week 4, 8 and 12, whereas SF-36 scores did not differ. CONCLUSION: Women who received 600 mg intravenous iron sucrose followed by standard oral iron after four weeks, replenished their iron stores more rapidly and had a more favorable development of the fatigue score indicating improved quality of life.

The biologic error in gestational length related to the use of the first day of last menstrual period as a proxy for the start of pregnancy.

OBJECTIVE: In a large unselected population of normal spontaneous pregnancies, to estimate the biologic variation of the interval from the first day of the last menstrual period to start of pregnancy, and the biologic variation of gestational length to delivery; and to estimate the random error of routine ultrasound assessment of gestational age in mid-second trimester. STUDY DESIGN: Cohort study of 11,238 singleton pregnancies, with spontaneous onset of labour and reliable last menstrual period. The day of delivery was predicted with two independent methods: According to the rule of Nägele and based on ultrasound examination in gestational weeks 17-19. For both methods, the mean difference between observed and predicted day of delivery was calculated. The variances of the differences were combined to estimate the variances of the two partitions of pregnancy. RESULTS: The biologic variation of the time from last menstrual period to pregnancy start was estimated to 7.0 days (standard deviation), and the standard deviation of the time to spontaneous delivery was estimated to 12.4 days. The estimate of the standard deviation of the random error of ultrasound assessed foetal age was 5.2 days. CONCLUSION: Even when the last menstrual period is reliable, the biologic variation of the time from last menstrual period to the real start of pregnancy is substantial, and must be taken into account. Reliable information about the first day of the last menstrual period is not equivalent with reliable information about the start of pregnancy.

[Mifepristone for induction of second trimester abortion]. / Mifepriston ved provosert abort i annet trimester.

BACKGROUND: We wanted to assess the effect of changing the regimen for termination from gemeprost to mifepristone and misoprostol. METHOD: The study was prospective from 1994 to 2001 and included 179 women who had a second trimester termination of pregnancy because of fetal malformations. Three different regimens were used: The traditional regimen with vaginal application of gemeprost (77 patients), pretreatment with mifpristone followed by gemeprost (40 patients), and pretreatment with mifepristone followed by misoprostol (62 patients). RESULTS: The induction-to-abortion interval was significantly shorter in the two groups receiving pretreatment with mifepristone than in the group treated solely with gemeprost, on average 9.7 and 9.5 hours compared to 22.7 hours (p < 0.001). All patients who received mifepristone aborted within 24 hours of start of induction, compared to 80 % of patients treated solely with gemeprost. INTERPRETATION: The combination of mifepristone and misoprostol provides a non-invasive and effective regimen for second trimester termination of pregnancy. Pretreatment with mifepristone represents a major improvement. Misoprostol is cheaper than gemeprost, is stored in room temperature, and can be used orally as well as vaginally.

[The epidemic of Caesarean section: has it reached Norway?]. / Har keisersnittsepidemien nådd Norge?

BACKGROUND: Women's right to decide on the mode of delivery is discussed, as well as the management of term breech deliveries. Obstetric practice may have changed as a consequence of ongoing debates. National caesarean section rates were stable at 12-13% during the 1990s, but no information has been provided about the development over the last two years. MATERIAL AND METHODS: Information about deliveries in obstetrical units in Norway, 1999 to 2002, was extracted from the Norwegian Patient Register. The number of deliveries was validated against information from Statistics Norway. The numbers of caesarean sections in 1999 and 2000 were validated against information from the Medical Birth Registry of Norway. RESULTS: The caesarean section rate increased slightly from 12.8% in 1999 to 13.0% in 2000. In 2001, there was a considerable increase to 14.9%; during the first 8 months of 2002, the rate was 15.1%. The change in practice appeared in the last months of 2000, coinciding with the publication of the term breech trial. However, only about one third of the increase can be attributed to a change in breech delivery. COMMENTS. Caesarean section is the most frequent major surgical procedure performed on hospitalised patients. In times of rapid changes in obstetric practice, monitoring of the development without time delay is called for.