Labor induction at 41+0 gestational weeks or expectant management for the nulliparous woman: The Finnish randomized controlled multicenter trial.

INTRODUCTION: Neonatal and maternal risks increase in term pregnancy as gestational age advances and become increasingly evident post-term. Management practices of late- and post-term pregnancies vary, and the optimal time point for intervention by labor induction is yet to be determined. MATERIAL AND METHODS: This randomized controlled trial of 381 nulliparous women with unripe cervices compared labor induction at 41+0 gestational weeks (early induction) with expectant management and labor induction at 41+5 to 42+1 gestational weeks (expectant management). This multicenter study included all five university hospitals and the largest central hospital in Finland. The study period was 2018-2022. Participants were randomized to either early induction (48.8%, n = 186) or expectant management (51.2%, n = 195) with equal randomization ratios of 1:1. This was a superiority trial, and the primary outcomes were rates of cesarean section (CS) and composite of adverse neonatal outcomes. The trial was registered at the ISRCTN registry (ISRCTN83219789, https://doi.org/10.1186/ISRCTN83219789). RESULTS: The rates of CS (16.7% [n = 31] vs. 24.1% [n = 47], RR 0.7 [95% CI: 0.5-1.0], p = 0.07) and a composite of adverse neonatal outcomes (9.7% [n = 18] vs. 14.4% [n = 28], RR 0.7 [95% CI: 0.4-1.2] p = 0.16) did not significantly differ between the groups, but the operative delivery rate was lower in the early induction group than in the expectant management group (30.6% [n = 57] vs. 45.6% [n = 89], p = 0.003). The rates of hemorrhage ≥1000 mL and neonatal weight ≥4000 g were also lower in the early induction group, as was the vacuum extraction rate in women with vaginal delivery. Of the women with expectant management, 45.6% (n = 89) had spontaneous onset of labor. No perinatal deaths occurred, but one case of eclampsia appeared in the expectant management group. CONCLUSIONS: Offering labor induction to nulliparous women at 41+0 gestational weeks may decrease the probability of operative delivery, postpartum hemorrhage, and neonatal weight ≥4000 g. However, this study was underpowered to affirm the trends of rising rates of CS and adverse neonatal outcomes in the expectant management group. Thus, expectant management could remain an option for some, as one in two women with expectant management had a spontaneous onset of labor.

Management of preterm labor: Clinical practice guideline and recommendation by the WAPM-World Association of Perinatal Medicine and the PMF-Perinatal Medicine Foundation.

This practice guideline follows the mission of the World Association of Perinatal Medicine in collaboration with the Perinatal Medicine Foundation, bringing together groups and individuals throughout the world, with the goal of improving the management of preterm labor. In fact, this document provides further guidance for healthcare practitioners on the appropriate use of examinations with the aim to improve the accuracy in diagnosing preterm labor and allow timely and appropriate administration of tocolytics, antenatal corticosteroids and magnesium sulphate and avoid unnecessary or excessive interventions. Therefore, it is not intended to establish a legal standard of care. This document is based on consensus among perinatal experts throughout the world in the light of scientific literature and serves as a guideline for use in clinical practice.

Introducing standard patient-reported measures (PRMs) into routine maternity care: A pre-implementation qualitative study on women's perspectives in Finland.

BACKGROUND: Systematically using standard patient-reported measures (PRMs) in clinical routines is trending. The International Consortium for Health Outcomes Measurement (ICHOM) has developed condition-specific standard sets of patient-centred measures, one of which is the Pregnancy and Childbirth Standard (PCB) set, where standard PRMs are included. There is limited knowledge on the use of ICHOM PCB set-included PRMs (ICHOM-PCB-PRMs) in routine care. This study investigates women's perspectives on the future implementation of standard ICHOM-PCB-PRMs in routine maternity care in Finland. METHODS: Semi-structured interviews were conducted. Pregnant and postpartum women were asked to evaluate each ICHOM-PCB-PRM in several dimensions, e.g., importance and quality of questions, and to provide their views on future implementation in terms of benefits, difficulties, and practices. With the predefined topics and themes, deductive analysis was applied. Ethical committee approval (HUS 220/880/2015) and research permissions were obtained. RESULTS: 22 women participated. Participants felt that most of the ICHOM-PCB-PRMs were important, relevant, understandable, and appropriately designed, and agreed that some changes in ICHOM-PCB-PRMs were needed, e.g., adding other important measures, changing the wording, and adding open-ended questions. Women would be hesitant to answer questions honestly if follow-up actions were unclear. Most "outcome" measures could be asked repeatedly as maternal health status changes over time, and "experience" measures could be asked separately for different service providers. Disagreements regarding data collection at birth were observed. PRMs were regarded as a way for women to express their thoughts and feelings. Our participants were concerned about the possible consequences of negatively answering the PREMs questions and the availability of follow-up care. Participants expected that they could answer short and easy questions digitally before appointments, and that instructions and follow-up actions based on their answers should be available. CONCLUSION: ICHOM-PCB-PRMs could be applicable in Finnish maternity care, but some modifications may be required. Careful consideration is needed regarding how and when PRMs questions are asked for eliciting more accurate and honest answers and minimizing women feeling judged, embarrassed, or offended. Follow-ups should be available according to women's responses and needs. This study provides insights on the adoption and implementation of standard PRMs in routine maternity care.

The acceptability of implementing patient-reported measures in routine maternity care: A systematic review.

INTRODUCTION: Patient-reported measures (PRMs) are becoming popular as they might influence clinical decisions, help to deliver patient-centered care, and improve health care quality. However, the limited knowledge and consensus about the acceptability of implementing PRMs in maternity care hinder their widespread use in clinical practice, and evidence-based recommendations are lacking. This systematic review aims to synthesize available evidence on the acceptability of implementing PRMs in routine maternity care. MATERIAL AND METHODS: Literature on the implementation of PRMs in maternity care was electronically searched in six databases (PsycARTICLES, PubMed, Scopus, Web of Science, Cochrane Database of Systematic Reviews, and CINAHL), screened and selected for the topic of "acceptability". Theoretical Framework of Acceptability was used as the basic framework guiding data analysis and synthesis. Evidence was thematically analyzed and synthesized. Mixed Method Appraisal Tool and GRADE-CERQual approach were used to assess the quality of studies and evaluate the confidence in the review findings. RESULTS: Overall, 4971 articles were screened. From 24 studies, we identified five themes regarding the acceptability of implementing PRMs in routine maternity care: (1) user's action and behavior, (2) stakeholders' attitudes, (3) perceived benefits, (4) perceived challenges and risks, and (5) stakeholders' preferences and suggestions on implementation. While pregnant and postpartum women, health professionals and other stakeholders involved in maternity care were generally positive about the implementation of PRMs in routine care and recognized the potential benefits (eg health improvement, women empowerment, care and services improvement and healthcare system advancement), they pointed out possible challenges and risks in answering PRMs questions, responding to answers, and setting up integrated information systems as well as suggested solutions in the aspects of PRMs data collection, follow-up care, and system-level management. The confidence in the review findings was moderate due to methodological limitations of included studies. CONCLUSIONS: Available empirical evidence suggested that the use of PRMs in routine maternity care is acceptable among stakeholders involved in maternity care and the potential benefits of its integration in routine clinical practice to healthcare improvement has been recognized. However, possible challenges in data collection, follow-up care arrangement and system-level integration should be appropriately addressed.

The impact of implementing patient-reported measures in routine maternity care: a systematic review.

INTRODUCTION: While there is growing interest in applying patient-reported measures (PRMs) in clinical routine, limited collective evidence of the impact of PRMs hinder their widespread use in specific contexts, such as maternity care. Our objective was to synthesize existing emperical evidence on the impact of implementing PRMs in routine maternity care. MATERIAL AND METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (version 2020). We electronically searched six databases for the literature on the implementation of PRMs in maternity care. A multi-level (woman, clinical, organizational, national and societal) analytic framework for analyzing and synthesizing emperically proven impacts of PRMs was developed. Quality was assessed using the Mixed Method Appraisal Tool. The GRADE-CERQual approach was used to assess the confidence in the review findings and arguments. The protocol was registered in PROSPERO (CRD42021234501). RESULTS: Overall, 4971 articles were screened. The emperical evidence, collected from 11 relevant studies, showed that the use of PRMs in routine maternity care could produce positive effects on clinical process (assessment and detection of health problems, clinical visit preparation, resource use, woman-professional communication, decision-making, woman-professional relationship, and care quality), and health behavior and outcomes (women's health and wellbeing, quality of life, health behavior, experiences and satisfaction with healthcare services), awareness, engagement and self-management of own health, and disclosure of health issues. The confidence in the review findings was low to moderate due to a limited number of studies, inadequate data and methodological limitations of included studies. CONCLUSIONS: The limited emperical evidence available suggested that the use of PRMs may have positive effects at the individual health level and clinical process level. However, the evidence was not strong enough to provide policy recommendations on the use of PRMs in routine maternity care. This review revealed limitations of currently available research, such as lack of generalizability and narrow scopes in investigating impact. Efforts are needed to improve the quality of research on the use of PRMs in routine maternity care by widening the study population, including different types of PRMs, and considering the effects of PRMs at different levels and domains of healthcare.

A qualitative study on professionals' attitudes and views towards the introduction of patient reported measures into public maternity care pathway.

BACKGROUND: The importance and potential benefits of introducing patient reported measures (PRMs) into health care service have been widely acknowledged, yet the experience regarding their implementation into practice is limited. There is a considerable paucity of research in adopting PRMs in maternity care routine. This study, which utilizes the PRMs included in Pregnancy and Childbirth (PCB) outcome set developed by International Consortium for Health Outcomes Measurement (ICHOM) as sample measures, aims to elicit Finnish professionals' views on PRMs and to explore the applicability of PRMs in Finnish public maternity care. METHODS: This qualitative study, applying semi-structured interviews, described the local professionals' views towards the application of PRMs in Finnish public maternity care. Professionals were asked to assess the PRMs defined in ICHOM PCB set and provide their expectations and concerns on the implementation of PRMs in Finnish public maternity service. RESULTS: Twenty professionals participated in the interviews. Participants agreed on the importance and relevance of the PRMs questions included in ICHOM PCB set for delivering and developing maternity care in Finland. However, they criticized the number and length of questions as well as the recommended time points of data collection. In addition, for a successful implementation, various steps like developing suitable questions, redesigning service pathway and protocols, and motivating women to respond to PRMs questions were considered to be important. Also, some potential obstacles, difficulties and risks associated with the implementation were underlined. CONCLUSION: This study indicates that the implementation of PRMs into Finnish public maternity service is possible, highly relevant and important. However, the adoption of PRMs into routine practice may be challenging and will require a series of efforts. This study shows viewpoints from Finnish professionals who have not participated in developing the ICHOM PCB standard set and provides important insights on the development and implementation of PRMs.

Contraceptive priorities among women seeking family planning services in Finland in 2017-2019.

OBJECTIVE: To assess how women's reproductive history, contraceptive experience and need of abortion care are associated with priorities for contraception. STUDY DESIGN: In this cross-sectional survey study, we gathered information on women's history of births and abortions, previous use and satisfaction with contraceptive methods, and features of contraceptive methods they value most. Women were recruited at public family planning and outpatient abortion clinics in the capital region of Helsinki, Finland. RESULTS: Of the 1006 women responding, 502 were recruited during visits for abortion care and 504 for contraceptive counseling. Women seeking abortion care more often had a history of abortion than women seeking contraceptive counseling (44% vs 11%), presented with a higher mean number of different contraceptive methods used (69% vs 55% with more than 2 previous methods), and were less often satisfied with the methods used (36% vs 60% satisfied with 2 out of 3 methods), p < 0.001 for all. In addition, women seeking abortion care had lower odds of prioritizing effectiveness (aOR 0.3, 95% CI 0.2-0.5), and higher odds of prioritizing lower hormonal levels or non-hormonal alternatives (aOR 2.0, 95% CI 1.3-3.2). There was no difference between the groups regarding priorities of lesser pelvic pain (aOR 0.7, 95% CI 0.5-1.1), regular period (aOR 01.2, 95% CI 0.8-1.9), or the method being easy to use (aOR 1.2, 95% CI 0.8-1.8). CONCLUSIONS: There is a contrast between guidelines emphasizing effectiveness in postabortion contraception, and many women's contraceptive priorities. IMPLICATION STATEMENT: Clinicians providing contraceptive counseling must be mindful of each individual's personal contraceptive priorities.

Spinal and epidural sufentanil and fentanyl in early labour.

BACKGROUND AND AIM: The analgesic effect on labour pain of either spinal or epidural sufentanil or fentanyl was tested in a total of 80 primiparous parturients at an early phase of the delivery. The aim of the study was to compare the level of analgesia achieved within 20 minutes. METHODS: The parturients were randomly assigned to groups receiving either spinal sufentanil (5 µg), epidural sufentanil (20 µg), spinal fentanyl (20 µg) or epidural fentanyl (100 µg), whereafter the parturients were monitored for reported pain during contraction and side effects for 30 minutes. The primary outcome was the level of analgesia achieved within 20 minutes, while the secondary outcome was the time until the administration of the first epidural bolus. RESULTS: At baseline, the mean maximum pain VAS was 86 (84-89) mm. At 20 minutes after spinal sufentanil, epidural sufentanil, spinal fentanyl or epidural fentanyl, the maximum VAS was 19 (7-31), 45 (32-59), 25 (10-39) or 52 (40-63) mm, respectively (P < .01 spin vs epid groups). There were no differences in efficacy between spinal or epidural sufentanil and fentanyl. The mean (95% CI) time to the activation of epidural analgesia was 151 (111-192), 130 (93-168), 177 (121-234) and 112 (80-143) minutes after spinal sufentanil, epidural sufentanil, spinal fentanyl and epidural fentanyl, respectively. CONCLUSIONS: In terms of a reduction of VAS score at 20 minutes, epidural sufentanil or fentanyl provide 63% and 60% of the analgesic effect of the corresponding spinal analgesia. Epidural sufentanil or fentanyl could be used in situations in which spinal/CSE administration is not possible or desired.

Success of trial of labor in women with a history of previous cesarean section for failed labor induction or labor dystocia: a retrospective cohort study.

BACKGROUND: The rates of cesarean section (CS) are increasing worldwide leading to an increased risk for maternal and neonatal complications in the subsequent pregnancy and labor. Previous studies have demonstrated that successful trial of labor after cesarean (TOLAC) is associated with the least maternal morbidity, but the risks of unsuccessful TOLAC exceed the risks of scheduled repeat CS. However, prediction of successful TOLAC is difficult, and only limited data on TOLAC in women with previous failed labor induction or labor dystocia exists. Our aim was to evaluate the success of TOLAC in women with a history of failed labor induction or labor dystocia, to compare the delivery outcomes according to stage of labor at time of previous CS, and to assess the risk factors for recurrent failed labor induction or labor dystocia. METHODS: This retrospective cohort study of 660 women with a prior CS for failed labor induction or labor dystocia undergoing TOLAC was carried out in Helsinki University Hospital, Finland, between 2013 and 2015. Data on the study population was obtained from the hospital database and analyzed using SPSS. RESULTS: The rate of vaginal delivery was 72.9% and the rate of repeat CS for failed induction or labor dystocia was 17.7%. The rate of successful TOLAC was 75.6% in women with a history of labor arrest in the first stage of labor, 73.1% in women with a history of labor arrest in the second stage of labor, and 59.0% in women with previous failed induction. The adjusted risk factors for recurrent failed induction or labor dystocia were maternal height < 160 cm (OR 1.9 95% CI 1.1-3.1), no prior vaginal delivery (OR 8.3 95% CI 3.5-19.8), type 1 or gestational diabetes (OR 1.8 95% CI 1.0-3.0), IOL for suspected non-diabetic fetal macrosomia (OR 10.8 95% CI 2.1-55.9) and birthweight ≥4500 g (OR 3.3 95% CI 1.3-7.9). CONCLUSIONS: TOLAC is a feasible option to scheduled repeat CS in women with a history of failed induction or labor dystocia. However, women with no previous vaginal delivery, maternal height < 160 cm, diabetes or suspected neonatal macrosomia (≥4500 g) may be at increased risk for failed TOLAC.

Placental and fetal hemodynamics in prolonged pregnancies.

OBJECTIVE: We hypothesized that Doppler measurements of the placental and fetal central and peripheral hemodynamics would predict adverse outcomes in prolonged uncomplicated singleton pregnancies. METHOD: A total of 160 participants were recruited to this study. Doppler measurements of placental and fetal hemodynamics as well as cardiotocography (CTG) were assessed prior to induction of labor at >41+ weeks. CTG during delivery, umbilical artery (UA) pH and base excess at birth and neonatal data were evaluated. RESULTS: In 16% of cases the outcome was unfavorable, defined as UA pH <7.10, 5-min Apgar score <7, cesarean delivery for fetal distress and/or need for admission to neonatal intensive care. There were no differences in the pulsatility indices of the uterine and umbilical arteries, middle cerebral artery, descending aorta, ductus venosus and inferior vena cava between the groups with favorable and unfavorable outcome. In addition, the ventricular inflow patterns, outflow velocities of the great arteries, cardiac outputs and myocardial performance indices were similar between the groups. CONCLUSION: Doppler parameters of the placental and fetal central and peripheral hemodynamics do not differ prior to the induction of labor in prolonged pregnancies with favorable and unfavorable outcomes. This suggests that their value is limited and that other clinical tools are needed for intermittent fetal surveillance in prolonged pregnancies. © 2016 John Wiley & Sons, Ltd.

[Evidence-based cesarean section]. / Tutkimusnäyttöön perustuva keisarileikkaus.

Cesarean delivery is the most frequent major surgery in Finland: in 2013 over 16% of the deliveries were via cesarean route. 27% of the mothers are estimated to face complications. Optimal surgical techniques and other operation-related measures aim to reduce the incidence of complications. Recommendations favor preoperative antibiotics, vaginal preparation, transversal skin incision, non-development of bladder flap, blunt cephalo-caudad uterine extension, spontaneous placental removal, late cord clamping, continuous sutures for uterine closure and subcutaneous skin sutures. Optimal measures will not only reduce complications in cesarean deliveries but bring cost savings and unify the clinical routines and training in specialization programs.

Diagnosis and treatment of severe hemolytic disease of the fetus and newborn: a 10-year nationwide retrospective study.

OBJECTIVE: Outcome after intrauterine transfusions due to severe hemolytic disease of the fetus and newborn. DESIGN: Nationwide population-based retrospective cohort study. SETTING: All women treated with intrauterine transfusions for hemolytic disease of the fetus and newborn in Finland in 2003-2012. POPULATION: 339 intrauterine transfusions, performed in 104 pregnancies of 84 women. METHODS: Information on antenatal screening of red cell antibodies and red cell units issued for intrauterine transfusion was obtained from the Finnish Red Cross Blood Service database, and obstetric and neonatal data from hospital records. MAIN OUTCOME MEASURES: Procedure-related complications, perinatal mortality, neonatal morbidity. RESULTS: Overall survival was 94.2% (95% confidence interval 89.7-98.7). There were four fetal and two neonatal deaths. Procedure-related fetal loss rate was 1.2% (95% confidence interval 0.04-2.4) per procedure and 3.8% (95% confidence interval 0.1-7.5) per pregnancy. Of the four procedure-related losses, three were due to technically difficult intrauterine transfusions causing infection and preterm birth. Of the live born infants, 19% (95% confidence interval 11.3-26.7) were born before 32 weeks' gestation. The incidence of severe neonatal morbidity (respiratory distress syndrome, severe cerebral injury, sepsis) was 22.2% (95% confidence interval 13.4-30.2). Poor outcome (death, severe neonatal morbidity) was negatively associated with gestational age at first transfusion (p = 0.001) and at birth (p = 0.00006). Follow-up of the infants was too incomplete to assess the neurodevelopmental outcome. CONCLUSIONS: Although overall survival is comparable with previous studies, our concern is procedure-related infections and preterm births. Close collaboration between the university hospitals is needed to ensure timely treatment, operator skills and systematic follow-up of the children.

Controlled ovarian hyperstimulation leads to high progesterone and estradiol levels during early pregnancy.

STUDY QUESTION: Are there differences in estrogen and progesterone secretion in singleton pregnancies, up to Week 11, between spontaneous pregnancies, after controlled ovarian hyperstimulation and fresh embryo transfer (COH + ET) and after frozen embryo transfer in a spontaneous cycle (FET)? SUMMARY ANSWER: Serum progesterone and estradiol (E2) concentrations after COH + ET were higher in early pregnancy, lasting up to Week 7-8, than FET and spontaneous pregnancies, while hormone levels after FET did not differ from spontaneous pregnancies. WHAT IS ALREADY KNOWN: The risk of adverse perinatal outcomes after COH + ET seems to be increased when compared with spontaneous pregnancies. One of the reasons suggested for this is related to ovarian hyperstimulation. STUDY DESIGN, SIZE, DURATION: This was a prospective cohort study consisting of three different groups of pregnant women which were followed-up weekly until Week 11 of their pregnancies. The spontaneous pregnancy group consisted of 41 women, the COH + ET group consisted of 39 and the FET group consisted of 30 women. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women in the control group with spontaneous conception were recruited from local prenatal clinics. Women in the COH + ET and FET groups were recruited from the Reproductive Unit of Oulu University Hospital. At each visit, a three-dimensional ultrasonography was performed to examine the ovarian volumes and vascularization. A blood sample was drawn to analyse progesterone and E2 levels. The pregnancy outcome was included in the analysis. MAIN RESULTS AND THE ROLE OF CHANCE: At pregnancy Week 5, the serum progesterone levels were higher after the COH + ET (median 312, inter-quartile range 183-480 nmol/l), when compared with the spontaneous (63, 52-80 nmol/l; P < 0.001) and FET (74, 48-96 nmol/l; P < 0.001) pregnancies. At Week 11, the P (189, 124-260 nmol/l) was still higher in the COH + ET group (FET 101, 78-120 nmol/l, P < 0.001; spontaneous 115, 80-139 nmol/l, P < 0.01) than the other two groups. The E2 levels at Week 5 were also significantly higher after COH + ET (4.1, 2.2-6.6 nmol/l) than in the spontaneous pregnancies (1.1, 0.7-1.6 nmol/l, P < 0.001) or after FET (0.7, 0.6-0.9 nmol/l, P < 0.001). The volume of the ovaries and the intraovarian vasculature in the COH + ET group were significantly higher when compared with the other two groups (P < 0.001). The birthweight was negatively correlated with the serum P (R -0.340, P < 0.01) and E2 (R= -0.275, P < 0.05) in pregnancy Weeks 5-8. In the multivariate analysis evaluating the factors affecting birthweight of the newborn, the significant factors were the length of gestation, maternal height and progesterone or E2 secretion during Weeks 5-8. LIMITATIONS, REASONS FOR CAUTION: Because of the low number of patients in this study, larger cohort studies are required to confirm the findings. WIDER IMPLICATIONS OF THE FINDINGS: The findings here indicate that COH-induced increased luteal activity should be evaluated by measuring steroid levels or the ovarian size or vascularity, rather than number of oocytes retrieved. If unphysiologically high steroid activity during pregnancy after COH contributes to the risk of adverse perinatal outcomes after fresh embryo transfer, milder stimulation protocols or even freezing of all of the embryos should be considered. STUDY FUNDING/COMPETING INTERESTS: This study was supported by a research grant from the Academy of Finland. The authors declare no conflicts of interest.

Effectiveness of electronic fetal monitoring with additional ST analysis in vertex singleton pregnancies at >36 weeks of gestation: an individual participant data metaanalysis.

OBJECTIVE: The purpose of this study was to assess the effectiveness of electronic fetal monitoring (EFM) alone and with additional ST analysis (EFM + ST) in laboring women with a singleton term pregnancy that is in cephalic presentation in the prevention of metabolic acidosis by the application of individual patient data metaanalysis. STUDY DESIGN: We conducted an individual patient data metaanalysis using data from 4 randomized trials, which enabled us to account for missing data and investigate relevant subgroups. The primary outcome was metabolic acidosis, which was defined as an umbilical cord-artery pH <7.05 and a base deficit that had been calculated in the extra cellular fluid compartment >12 mmol/L. We performed 8 explanatory subgroup analyses for 8 different endpoints. RESULTS: We analyzed data from 12,987 women and their newborn infants. Metabolic acidosis was present in 57 women (0.9%) in the EFM + ST group and 73 women (1.1%) in the EFM alone group (relative risk [RR], 0.76; 95% CI, 0.53-1.10). Compared with EFM alone, the use of EFM + ST resulted in a reduction in the frequency of instrumental vaginal deliveries (RR, 0.90; 95% CI, 0.83-0.99) and fetal blood samples (RR, 0.49; 95% CI, 0.44-0.55). Cesarean delivery rates were comparable between both groups (RR, 0.99; 95% CI, 0.91-1.09). Subgroup analyses showed that EFM + ST resulted in fewer admissions to a neonatal intensive care unit for women with a duration of pregnancy of >41 weeks (RR, 0.61; 95% CI, 0.39-0.95). CONCLUSION: EFM + ST does not reduce the risk of metabolic acidosis, but it does reduce the need for instrumental vaginal deliveries and fetal blood sampling.

Effect of parity and fetal sex on placental and luteal hormones during early first trimester.

OBJECTIVE: Earlier studies have shown that maternal hormone secretion during late first or second trimester may be affected by gravidity. We examined the luteoplacental hormone secretion during 5-11 weeks of gestation in relation to gravidity. METHOD: Forty-one naturally conceived pregnancies underwent weekly assessment of serum human chorionic gonadotrophin, progesterone and 17-OH progesterone, estradiol, testosterone, and pregnancy-associated plasma protein A levels. In addition, the volume and the vasculature of the dominant ovary with corpus luteum were assessed with the use of a 3-dimensional power Doppler ultrasonography. Areas under the curve for hormonal and ultrasonographic parameters were calculated. RESULTS: Twenty-two out of the 41 women were pregnant for the first time. All the pregnancies were uncomplicated and resulted in term deliveries of appropriately grown newborns. During pregnancy weeks 5-11, the secretion (area under the curve) of human chorionic gonadotrophin (6.54 ± 0.03 vs 6.39 ± 0.05, p = 0.010), progesterone (3.49 ± 0.02 vs 3.36 ± 0.03, p = 0.003), and 17-OH progesterone (2.73 ± 0.03 vs 2.62 ± 0.03, p = 0.013) were higher in primigravid than in multigravid women. No other differences were detected between primigravid and multigravid women. CONCLUSION: The placental function already differs between primigravid and multigravid women during the first weeks of pregnancy, which reflects the corpus luteal function.

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.

[Abdominal pregnancy]. / Vatsaonteloraskaus on diagnostinen haaste.

Abdominal pregnancy is a rare form of ectopic pregnancy with potentially life-threatening complications both to mother and the fetus. Due to infrequency of abdominal pregnancy, it is often unsuspected and remains a diagnostic challenge despite improvements in imaging techniques. We report a case of advanced abdominal pregnancy after in vitro-fertilization. The diagnosis was made by magnetic resonance imaging (MRI) at 30 weeks' gestation, and a healthy baby was successfully delivered by laparotomy. The mother and the baby survived without any long-term complications.

Effect of rising hCG levels on the human corpus luteum during early pregnancy.

BACKGROUND: During early pregnancy, the most important task of the corpus luteum (CL) is to produce sufficient progesterone until the luteoplacental shift occurs. Progesterone production is closely related to the extensive vasculature surrounding and supplying the CL. The synthesis of both progesterone and factors controlling the vasculature in the CL is regulated by hCG, which is released initially at rising levels from the placenta. The primary aim of this research was to evaluate changes in the CL vasculature during early pregnancy. METHODS: Twenty naturally conceived pregnancies were examined weekly from weeks 5 to 11. At each visit, blood samples were obtained to determine the concentrations of hCG, progesterone and 17-OH progesterone (17-OHP). The vasculature in the ovaries was assessed using three-dimensional power Doppler ultrasonography. RESULTS: The vascular supply in the ovary containing the CL was greatest at week 5, and thereafter, declined continuously until week 11. The decrease in the vasculature correlated with the decrease in 17-OHP. Mean hCG levels reached a maximum at week 8, progesterone levels reached the nadir at week 7 and increased after that. CONCLUSIONS: Vasculature in the CL appears to be created already by the fifth week of pregnancy and it does not enlarge despite rising hCG levels. The activity of the CL during pregnancy may be measured non-invasively by assessing its vasculature with three-dimensional ultrasonography.

Interobserver agreement in the assessment of intrapartum automated fetal electrocardiography in singleton pregnancies.

OBJECTIVE: To study interobserver agreement in the assessment of intrapartum automated fetal electrocardiogram ST interval analysis (STAN). DESIGN: Observational study. SETTING: Labor ward in tertiary level university hospital. Sample. Two hundred (140 reassuring and 60 non-reassuring) STAN recordings on non-selected women with singleton, vertex, term pregnancies were selected from our archive. Samples of 60-min were analysed from the end of each recording, excluding the last 30 min before delivery. METHODS: Three consultants, who had undergone STAN training and had clinical experience in using STAN, reviewed the recordings using cardiotocography (CTG) and ST information with no clinical data. The reviewers were asked to follow STAN guidelines and 1 to classify the CTG as normal, intermediary, abnormal, or preterminal, and 2 to make a clinical decision on labor management. MAIN OUTCOME MEASURES: Interobserver agreement evaluated by weighted kappa (kappa(w)) values and the proportion of agreement. RESULTS: In CTG classification, the interobserver agreement between three observers was moderate (kappa(w), 0.47-0.48). The proportion of agreement was 56-59%. In clinical decision-making, kappa(w) values varied from 0.47 to 0.60, and the proportion of agreement was 80-86%. CONCLUSIONS: In non-selected term pregnancies, the interobserver agreement among experienced obstetricians in the classification of CTG and clinical decision-making according to STAN guidelines is moderate at best.