The impact of maternal obesity, age, pre-eclampsia and insulin dependent diabetes on severe maternal morbidity by mode of delivery-a register-based cohort study.

PURPOSE: To determine the rate of severe maternal morbidity related to delivery by delivery mode and to assess if the impact of studied risk factors varies by delivery mode. METHODS: A register-based study including all women having singleton delivery in Finland in 2007-2011, n = 292,253, data derived from the Finnish Medical Birth Registry and Hospital Discharge Registry. Diagnoses and interventions indicating a severe maternal complication were searched and the mode of delivery was assessed by data linkage. The impact of obesity, maternal age 35 years or more, pre-eclampsia and insulin dependent diabetes on severe maternal morbidity (all severe complications, severe infections and severe) was studied in each mode of delivery and calculated as Odds ratios. RESULTS: The overall incidence of severe complications was 12.8/1,000 deliveries. The total complication rate was lowest in vaginal deliveries (VD) in all risk groups. Obesity increased the risk for all severe complications and severe infections in the total population, but not significantly in specific delivery modes. Age increased the risk of hemorrhage in VD. Pre-eclampsia increased the risk for hemorrhage in all deliveries except elective CS. In women with pre-eclampsia, overall morbidity was similar in VD, attempted VD and elective CS. The presence of any studied risk factor increased the risk for complications within the risk groups by the high proportion of emergency CS performed. CONCLUSIONS: An attempt of VD is the safest way to deliver even for high-risk women with the exception of women with pre-eclampsia, who had a similar risk in an attempt of VD and elective CS.

Variation in cesarean section rates is not related to maternal and neonatal outcomes.

OBJECTIVE: The aim of this study was to compare the rate of cesarean sections in 12 delivery units in Finland, and to assess possible associations between cesarean section rates and maternal and neonatal complications. DESIGN: Prospective multicenter cohort study. SETTING: The 12 largest delivery units in Finland. POPULATION: Total obstetric population between 1 January 2005 and 30 June 2005 (n = 19 764). METHODS: Prospectively collected data on 2496 cesarean sections and data derived from the Finnish Birth Register on all deliveries in these units were compared. Cesarean section rates and maternal complication rates were adjusted for known risk factors. MAIN OUTCOME MEASURES: Cesarean section rate, maternal complications related to cesarean section, and neonatal asphyxia. RESULTS: The cesarean section rates varied significantly between the hospitals (12.9-25.1%, p < 0.0001), as did the maternal complication rates related to cesarean section (13.0-36.5%, p < 0.0001). There was no relation between maternal complications and the cesarean section rate. The differences remained after adjusting for risk factors. Neonatal asphyxia rates varied between 0.14 and 2.8% (p < 0.0001) and were not related to the cesarean section rates. CONCLUSIONS: The rates of cesarean section, maternal complications and neonatal asphyxia vary markedly between different delivery units. Good maternal and neonatal outcomes can be achieved with cesarean section rates <15%.

[Update on current care guidelines: diagnosis and treatment of sexually transmitted infections]. / Sukupuolitautien diagnostiikka ja hoito.

Recognition of common sexually transmitted infection (STI) syndromes allows more efficient diagnosis and treatment. These evidence-based guidelines provide advice on the management of STIs, including the use of the appropriate diagnostic methods and therapeutic regimens. Early and appropriate therapy has the potential to significantly reduce the long-term complications of STIs. The prevention of further infection through the counselling and treatment of partners contributes to the sexual health of patients.

Quantification of Ureaplasma urealyticum DNA in the amniotic fluid from patients in PTL and pPROM and its relation to inflammatory cytokine levels.

OBJECTIVE: To study the effect of the amniotic fluid quantity of Ureaplasma urealyticum DNA on inflammatory response levels in women with preterm labor (PTL) and preterm prelabor rupture of membranes (pPROM). DESIGN: A prospective multi-center follow up study. SETTING: Sahlgrenska University Hospital, Goteborg, Sweden and Turku University Hospital, Turku, Finland. SAMPLE: Eleven U. urealyticum positive samples obtained after transabdominal amniocenteses in 197 women presenting with PTL and pPROM. METHODS: The U. urealyticum positive samples were analyzed with real-time polymerase chain reaction, using the Lightcycler instrument with primers specific for U. urealyticum 16 S rDNA. The amniotic fluid samples were analyzed for tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-1beta and IL-10 with enzyme-linked immunosorbent assays. MAIN OUTCOME MEASURES: Correlation between U. urealyticum DNA concentrations in the amniotic fluid and inflammatory cytokine levels. RESULTS: The concentrations of U. urealyticum DNA varied between 0.024 and 934 microg/mL. A significant correlation between U. urealyticum DNA and TNF-alpha level was observed. No correlation with the other cytokines was found. Women with PTLhad higher levels of U. urealyticum DNA and a different cytokine pattern than women with pPROM. CONCLUSIONS: U. urealyticum in the amniotic fluid induces an inflammatory reaction in a dose dependent manner and the quantity of U. urealyticum DNA is well correlated with the level of the inflammatory cytokine TNF-alpha.

Clinical and immunologic evaluation of women with multiple sclerosis during and after pregnancy.

BACKGROUND: Multiple sclerosis (MS) is a disabling autoimmune disease of the central nervous system, typically affecting women of childbearing years. Although the disease course of MS is highly unpredictable, disease activity is almost invariably halted during pregnancy. After delivery, however, the relapse rate increases. Despite early recognition of this pattern of disease activity, its explanation remains a mystery. OBJECTIVE: The aim of this study was to elucidate the underlying mechanisms responsible for the amelioration of MS during pregnancy and for its reactivation after delivery. METHODS: This Finnish prospective study included clinical and immunologic follow-up of patients with MS during pregnancy and 6 months into the postpartum period. Groups of patients with MS who were not pregnant, along with pregnant and nonpregnant healthy women, served as controls. Laboratory investigations included subtype analysis of T, B, and natural killer (NK) cells during and after pregnancy, using immunofluorescence staining and fluorescence-activated cell sorting analysis RESULTS: The clinical and immunologic follow-up data from 42 pregnant patients with MS indicated that the percentage of circulating NK cells decreases during the last trimester of pregnancy and increases again soon after the delivery. This correlates with disease activity as measured by annualized relapse rate. Early postpartum treatment with interferon-0 was effective in preventing relapses, and good response to postpartum treatment coincided with a reduction in the circulating NK cell levels. CONCLUSIONS: Our findings have implications for the treatment and follow-up of pregnant women with MS. To prevent postpartum relapses, disease-modifying treatment should be initiated as early as possible.

Transfer of proinflammatory cytokines across term placenta.

OBJECTIVE: Increased concentrations of proinflammatory cytokines in amniotic fluid indicate the presence of intra-amniotic inflammation and increase the risk of preterm birth, cerebral palsy, and bronchopulmonary dysplasia. The purpose of this study was to find out if the proinflammatory cytokines, tumor necrosis factor alpha (TNF-alpha), interleukin (IL)-1beta, and IL-6, transfer across the placenta, and thereby determine whether intra-amniotic inflammatory response, measured from the amniotic fluid, is of maternal or fetal origin. METHODS: Nineteen placentas from healthy women undergoing elective cesarean delivery at term with intact membranes and without labor, were dually perfused ex vivo in an open circulation system for either 30 minutes or 2 hours. Tumor necrosis factor-alpha, IL-1beta, and IL-6 were added to maternal or fetal circulation in a concentration usually found in chorioamnionitis. As a reference, placentas without added cytokine were also perfused. The concentrations of cytokines were determined by enzyme immunoassays (enzyme-linked immunosorbent assay [ELISA]). RESULTS: After the addition of the cytokine to the arterial perfusate, the venous concentration on the same side of the placenta increased rapidly and reached a plateau at 10 minutes. No transfer of any cytokine in either direction was detected. Some endogenous release of IL-6 was observed in response to the perfusion. CONCLUSION: Proinflammatory cytokines do not cross normal term placenta.

Ureaplasma urealyticum: no independent role in the pathogenesis of bronchopulmonary dysplasia.

BACKGROUND: Ureaplasma urealyticum has been linked to short and long-term morbidity of preterm infants. We wanted to analyze if it has an independent role in the pathogenesis of bronchopulmonary dysplasia if prenatal history with possible exposure to intrauterine infection is taken into account. METHODS: Lower respiratory tract colonization with U. urealyticum was analyzed from 49 infants born before the 30th week of gestation. The need for supplemental oxygen at the age of 28 days and 36 gestational weeks was studied. RESULTS: Forty-five percent of the 33 infants born after spontaneous onset of labor were colonized with U. urealyticum, while none of the electively born were. If analyzed based on the Ureaplasma colonization, bronchopulmonary dysplasia was more common in the colonized infants at the age of 28 days (OR 4.57, 95% CI 1.18-17.68), but not at the gestational age of 36 weeks (OR 1.00). Based on the prenatal history, the OR of bronchopulmonary dysplasia in infants born after spontaneous onset of labor was greater than in infants born electively both at the age of 28 days (OR 4.33, 95% CI 0.83-22.75) and at 36 weeks of gestation (OR 2.8, 95% CI 0.30-26.42). CONCLUSIONS: If possible exposure to intra-amniotic inflammation is taken into account, U. urealyticum seems not to have an independent role in the pathogenesis of bronchopulmonary dysplasia. Its role has been overemphasized, as it is the most common cause of intra-amniotic bacterial infection.

Seroprevalence, incidence of prenatal infections and reliability of maternal history of varicella zoster virus, cytomegalovirus, herpes simplex virus and parvovirus B19 infection in South-Western Finland.

OBJECTIVE: To study seroprevalence and incidence and fetal transmission of varicella zoster virus (VZV), cytomegalovirus (CMV), herpes simplex virus (HSV) types 1 and 2 and parvovirus B19 infections during pregnancy and to evaluate the reliability of maternal past history of VZV, HSV and parvovirus infections. DESIGN: Prospective study of parturient women. SETTING: South-Western Finland. PARTICIPANTS: Five hundred and fifty-eight parturient women. METHODS: IgG and IgM antibodies against VZV, CMV, HSV-1 and -2, and parvovirus B19 were measured from maternal serum in the first trimester and at delivery and from cord serum, mother's own information of her past infections was compared with her serological status. MAIN OUTCOME MEASURES: Seroprevalence, seroconversions and fetal transmission of VZV, CMV, HSV and parvovirus B19, reliability of maternal history of VZV, HSV and parvovirus B19. RESULTS: Seroprevalences were 96.2% for VZV, 56.3% for CMV, 54.3% for HSV, 46.8% for HSV-1, 9.3% for HSV-2 and 58.6% for parvovirus B19. Parity was associated with CMV seropositivity, maternal age differed only between HSV-2 seropositive and seronegative women, while area of residence (urban or rural) had no effect. Six seroconversions were observed: two VZV, one CMV and three parvovirus infections. No cases of primary HSV infections occurred. Fetal transmission was observed in two cases of parvovirus infection. No infants with anti-CMV IgM antibodies were born to CMV immunised women. False positive history of chickenpox was given only by 1.5% of the women, history of herpes infections was less reliable, and history of parvovirus infection was unreliable. CONCLUSIONS: Seroprevalence and the risk of viral infections during pregnancy cannot be extrapolated from one pregnant population to another.

Cervical ureaplasma urealyticum colonization: comparison of PCR and culture for its detection and association with preterm birth.

We developed a 16S ribosomal (r) RNA gene-based PCR assay specific for Ureaplasma urealyticum and compared it with culture. We also wanted to assess the role of cervical U. urealyticum colonization in preterm births. Cervical swabs from 100 women with preterm contractions and from 50 asymptomatic pregnant women were collected and analyzed using PCR. The PCR and culture methods were compared using the samples from the asymptomatic patients. PCR and culture were equally effective at detecting U. urealyticum. Cervical colonization correlated with preterm delivery, with rates of 71% and 37% for those delivering preterm and those with term delivery, respectively (p = 0.008). The relative risk of preterm delivery if colonized with U. urealyticum was 3.34. 16S rRNA gene-based PCR proved to be a useful tool for detecting U. urealyticum compared to culture. Lower genital tract colonization with U. urealyticum was associated with preterm birth.