Pelvic floor disorders and impact on sexual function: a cross-sectional study among non-sexually active and sexually active women.

Background: Pelvic floor disorders are common and associated with impaired sexual function in women. Aim: To assess women with pelvic floor disorders and describe factors associated with not being sexually active and those associated with sexual function in sexually active women. Methods: A cross-sectional study was conducted that included nonpregnant women with symptoms of pelvic floor disorders who were referred to the urogynecologic and surgical outpatient clinic at 2 Norwegian university hospitals: St Olavs Hospital, Trondheim University Hospital, and the University Hospital of Northern Norway, Tromsø. Women answered a questionnaire anonymously. Outcomes: Pelvic Organ Prolapse Incontinence Sexual Questionnaire-IUGA Revised. Results: Of 157 respondents, 111 (71%) reported being sexually active (with or without a partner), and 46 (29%) reported not being sexually active. As compared with sexually active women, not sexually active women were older (mean ± SD, 60.2 ± 13.3 vs 51 ± 12.1 years; P < .001), more were menopausal (78% vs 47%, P = .001), and more had symptom debut <1 year (31% vs 9%, P < .001). They reported more distress related to pelvic floor disorders, especially pelvic organ prolapse. In a multivariate logistic regression analysis, menopausal women and women with symptom debut <1 year were 4 times more likely to be not sexually active than premenopausal women (odds ratio, 4.0; 95% CI, 1.7-9.2) and women with symptom debut ≥1 year (odds ratio, 4.0; 95% CI, 1.5-10.7). In sexually active women, colorectal-anal distress was negatively associated with 5 of 6 domains of sexual function: arousal/orgasm (ß = -0.36; 95% CI, -0.02 to -0.005), partner related (ß = -0.28; 95% CI, -0.01 to -0.002), condition specific (ß = -0.39; 95% CI, -0.002 to -0.009), global quality (ß = -0.23; 95% CI, -0.02 to -0.002), and condition impact (ß = -0.34; 95% CI, -0.02 to -0.006). Clinical Implications: Health care professionals should discuss sexual function in patients with pelvic floor disorders, especially menopausal women and women with colorectal-anal symptoms. Strengths and Limitations: The study used condition-specific measures and recruited women from 2 university hospitals with wide range of age. Limitations include the small sample size and wide confidence intervals. The number of women who considered themselves not sexually active was low, and item nonresponse levels among these women where somewhat high. Of 625 eligible women, 200 (32%) answered the questionnaire. Sexual health and sexual function are still surrounded with taboo, and some women were probably not comfortable answering the questions. Conclusion: Menopausal women and women with recent onset of symptoms of pelvic floor disorders are more likely to be sexually inactive, and colorectal-anal symptoms have the most negative impact on sexual function in sexually active women.

The association between serum vitamin D status and dental caries or molar incisor hypomineralisation in 7-9-year-old Norwegian children: a cross-sectional study.

BACKGROUND: Research focusing on the association between serum vitamin D and oral health outcomes in children, such as dental caries and molar incisor hypomineralisation (MIH), shows inconsistent results. Previous studies have predominantly investigated dental caries and MIH as dichotomized outcomes, which limits the information on their distribution. In addition, the methods used for analysing serum vitamin D have varied. The present study aimed to investigate potential associations between serum vitamin D status measured by Liquid Chromatography with Tandem Mass Spectrometry (LC-MS/MS) and the prevalence, as well as the number of teeth, affected by dental caries or MIH among 7-9-year-old Norwegian children. METHODS: The study had a cross-sectional design and included 101 children aged 7-9 years. Serum 25-hydroxyvitamin D (25(OH)D) was measured and included as continuous (per 25 nmol/l) and categorised (insufficient (< 50 nmol/l) and sufficient (≥50 nmol/l)) exposure variables. Adjusted negative binomial hurdle models were used to investigate the potential associations between serum vitamin D and the oral health outcomes (dental caries and MIH) adjusted for sex, age, body mass index, season of blood draw, and mother's educational level. RESULTS: Of the 101 children in the total sample, 27% had insufficient vitamin D levels (< 50 nmol/l). The descriptive analysis indicated that the children with insufficient vitamin D levels had a higher prevalence (33.3%) and a higher number of teeth affected by dental caries (mean (SD) = 0.7 (1.4)), compared to children with sufficient levels of vitamin D (21.6% and mean (SD) = 0.4 (0.8), respectively). The same holds for MIH, with a higher prevalence (38.5%) and a higher number of teeth affected (mean (SD) = 1.2 (2.3)), compared to children with sufficient levels of vitamin D (30.1% and mean (SD) = 0.8 (1.6), respectively). However, in the adjusted hurdle model analysis, neither the prevalence or number of teeth affected by caries or MIH showed statistically significant associations with having insufficient or lower vitamin D levels. CONCLUSIONS: Vitamin D status was not significantly associated with the prevalence and number of teeth affected by caries and MIH among the participating children. Large prospective studies with multiple serum vitamin D measurements and oral examinations throughout childhood are warranted to elucidate the relationship.

Employing fasting plasma glucose to safely limit the use of oral glucose tolerance tests in pregnancy: a pooled analysis of four Norwegian studies.

Background/objective: There is no international consensus about the optimal approach to screening and diagnosis of gestational diabetes mellitus (GDM). Fasting plasma glucose (FPG) has been proposed as an alternative universal screening test to simplify the diagnosis of GDM. We investigate the ability of the FPG to predict a 2-hour glucose value below the cut-off for GDM, thereby "ruling out" the necessity of a full OGTT and assess the proportion of GDM-related complications associated with the identified FPG level. Materials and methods: This study included secondary data from four Norwegian pregnancy cohorts (2002-2013), encompassing 2960 women universally screened with late mid-pregnancy 75g OGTT measuring FPG and 2-hour glucose. For a range of FPG thresholds, we calculated sensitivity to predict elevated 2-hour glucose, number of OGTTs needed and percentage of GDM cases missed, applying modified World Health Organization (WHO) 2013 criteria (2013WHO) and 2017 Norwegian criteria (2017Norwegian). We analyzed pregnancy outcomes for women above and below our selected threshold. Results: The prevalence of GDM was 16.6% (2013WHO) and 10.1% (2017Norwegian). A FPG threshold of 4.7 mmol/L had a sensitivity of 76% (2013WHO) and 80% (2017Norwegian) for detecting elevated 2-hour glucose, with few missed GDM cases (2.0% of those ruled out and 7.5% of all GDM cases for 2013WHO, and 1.1% of those ruled out and 7% of all GDM cases for 2017Norwegian). When excluding women with FPG <4.7mmol/l and those with GDM based on FPG, only 24% (2013WHO) and 29% (2017Norwegian) would require OGTT. Women with FPG <4.7mmol/l, including missed GDM cases, had low risk of large-for-gestational-age newborns, cesarean section and operative vaginal delivery. Conclusion: A FPG threshold of 4.7mmol/l as a first step when screening for GDM could potentially eliminate the need for OGTT in 70-77% of pregnancies. Women with FPG below this threshold appear to carry low risk of GDM-associated adverse pregnancy outcomes.

Amsterdam complex pelvic pain symptom scale with subscales: Based on a Norwegian translation, psychometric assessment and modification of the Amsterdam hyperactive pelvic floor scale.

INTRODUCTION: Women with an abnormally high pelvic floor muscle tone may have a clinical presentation that is complex, involving urinary, anorectal and/or sexual dysfunction, genital/pelvic pain and psychological distress. The Amsterdam Hyperactive Pelvic Floor Scale (AHPFS) is a Dutch 30-item condition-specific self-report questionnaire developed to measure these complex pelvic pain symptoms. The aim of this study was to translate the Dutch version into Norwegian, to assess the psychometric properties, and to present a valid factor structure. MATERIAL AND METHODS: Translation, back-translation and a review of the back-translated version were performed. Thereafter, a pilot test including feedback from six clinical experts and cognitive interviews with 11 patients from the target group was conducted. Next, a field test was performed among women who were (1) patients at the gynecological outpatient clinic/pelvic floor physiotherapist at St. Olav's Hospital, (2) members of the Vulvodynia or the Endometriosis Patient Associations or (3) female students and employees from the Faculty of Medicine and Health Science, the Norwegian University of Science and Technology, in a web-based survey. To ensure a sample with symptomatic women, only women who scored ≥11 according to the Dutch prespecified factor structure were included in the statistical analyses (n = 232). RESULTS: Content/face validity demonstrated that the questionnaire was perceived as relevant, comprehensive and understandable. Some adjustments in the instructions of the questionnaire and the response categories were made, which lead to the Norwegian translation ACPPS-30. Assessment of the questionnaire's dimensionality revealed a five-factor structure similar to the original Dutch Amsterdam Hyperactive Pelvic Floor Scale (AHPFS) but without the Urinary tract infection factor and seven other items. The translated and modified ACPPS-16 total score and subscales correlated as expected with scales measuring similar conditions. Test-retest reliability demonstrated good stability for scales (intraclass correlation coefficient 0.85-0.93) and single items (weighted kappa values from 0.34 to 0.90). CONCLUSIONS: A modified Norwegian version ACPPS-30 was presented, in addition to a shorter version with only 16 of the translated items distributed among five factors similar to the original Dutch version (ACPPS-16). Both versions proved to be valid, stable and reliable tools to investigate complex pelvic pain symptoms possibly due to an abnormally high-toned pelvic floor muscle.

Symptoms of complex pelvic pain: A survey in three cohorts of women.

INTRODUCTION: There has been increased interest in addressing chronic pelvic pain and its complexity in women. The often multifactorial etiology of chronic pelvic pain and its heterogeneous presentation, however, make the condition challenging to manage. Overlap with other pain-related conditions is frequently reported, and chronic pelvic pain may impact sexual function. Nevertheless, little is known about the symptom burden of chronic pelvic pain and more complex pelvic pain in different groups of women. Thus, the aim of our study was to use a newly validated Norwegian version of the Amsterdam Complex Pelvic Pain Symptom Scale (ACPPS) to describe and compare the symptom severity of complex pelvic pain in three cohorts of women and to assess associations between demographic and gynecological characteristics and the severity of the condition. MATERIAL AND METHODS: In our cross-sectional study, we collected self-reported data from patients referred to gynecological outpatient clinics, members of vulvodynia or endometriosis patient associations, and healthy volunteers. The 397 participants (47% response rate) completed an online survey about their demographic and gynecological characteristics and symptoms related to complex pelvic pain, including the Norwegian ACPPS. Score means on questionnaires, with standard deviations and 95% confidence intervals, were recorded. We used Pearson's chi-square test, Analysis of variance and multivariable linear regression were used to assess associations of demographic and gynecological characteristics with ACPPS scores. RESULTS: Members of the patient associations had significantly higher self-reported symptom burden than patients and volunteers. Symptom burden was lower among older and postmenopausal women, and unemployed women scored higher than employed ones. Especially high scores on the ACPPS were found among women with complaints of chronic pelvic pain, at least moderate pelvic pain intensity, and/or chronic vulvar pain. Women who had experienced sexual assault and/or reported low sexual function also reported high scores. In multivariable regression, fibromyalgia, low mental health and past sexual assault were found to be associated with high scores on the ACPPS. CONCLUSION: Many women in our study reported complex pelvic pain, and overlap with other pain-related conditions, low mental health and past sexual assault was associated with high symptom burden. Those findings support taking a biopsychosocial approach to treating women who present with such complaints.

Adverse pregnancy outcomes among women in Norway with gestational diabetes using three diagnostic criteria.

INTRODUCTION: The aim of this study was to examine the risk of adverse perinatal outcomes in women diagnosed with GDM by the World Health Organization (WHO) 1999 criteria, and in those retrospectively identified by the Norwegian-2017 and WHO-2013 criteria but not by WHO-1999 criteria. We also examine the effect of maternal overweight/obesity and ethnicity. MATERIAL AND METHODS: We used pooled data from four Norwegian cohorts (2002-2013), encompassing 2970 mother-child pairs. Results from universally offered 75-g oral glucose tolerance tests measuring fasting plasma glucose (FPG) and 2-hour glucose (2HG) were used to assign women into three diagnostic groups: Diagnosed and treated by WHO-1999 (FPG≥7.0 or (2HG ≥7.8 mmol/L), identified by WHO-2013 (FPG ≥5.1 or 2HG ≥8.5 mmol/L), and identified by Norwegian-2017 criteria (FPG ≥5.3 or 2HG ≥9.0 mmol/L). Perinatal outcomes included large-for-gestational-age (LGA) infants, cesarean section, operative vaginal delivery, preterm birth and preeclampsia. RESULTS: Compared to the non-GDM group, women diagnosed with GDM by either of the three criteria had an increased risk of large-for-gestational-age infants (adjusted odds ratios (OR) 1.7-2.2). Those identified by the WHO-2013 and Norwegian-2017 criteria but not diagnosed and treated by WHO-1999 criteria had an additional increased risk of cesarean section (OR 1.36, 95% CI 1.02,1.83 and 1.44, 95% CI 1.03,2.02, respectively) and operative vaginal delivery (OR 1.35, 95% CI 1.1,1.7 and 1.5, 95% CI 1.1,2.0, respectively). The proportions of LGA neonates and cesarean section were higher for women with GDM in both normal-weight and overweight/obese women. Asians had a lower risk of delivering large-for-gestational-age infants than Europeans applying national birthweight references, but maternal glucose values were similarly positively associated with birthweight in all ethnic groups. CONCLUSIONS: Women who met the WHO-2013 and Norwegian-2017 criteria, but were not diagnosed by the WHO-1999 criteria and therefore not treated, had an increased risk of LGA, cesarean section and operative vaginal delivery compared to women without GDM.

Physical health and neurodevelopmental outcome in 7-year-old children whose mothers were at risk of gestational diabetes mellitus: a follow-up of a randomized controlled trial.

INTRODUCTION: Children born to mothers with gestational diabetes mellitus (GDM) are at risk of metabolic disturbances such as diabetes mellitus and overweight. However, few have examined the outcome of children whose mothers were at risk of GDM. The aim of the study was to investigate how mothers' risk of developing GDM affects physical health and neurodevelopment of the children at 7 years of age. MATERIAL AND METHODS: This is a secondary analysis of a follow-up study of a multicenter randomized controlled trial including 855 pregnant women, carried out at St. Olavs Hospital, Trondheim University Hospital, and Stavanger University Hospital in Norway from 2007 to 2009. Risk factors for developing GDM included age >40 years, diabetes in near family, previous child with birthweight ≥4500 g and pre-pregnancy body mass index (BMI) ≥25 kg/m2 . Data on GDM risk factors were available for 750 women, who were divided into a risk group if they had one or more risk factors for developing GDM (n = 238) and a no risk (n = 512) group. At 7 years of age, 72 children born to mothers in the risk group and 194 children born to mothers in the no risk group participated. The children's height, weight and physical activity were reported by their parents. Neurodevelopmental outcomes were assessed by using the Five-to-Fifteen questionnaire, which includes motor skills, executive functions, perception, memory, language, social skills, and emotional/behavioral problems. RESULTS: Most women had only one risk factor for GDM, and pre-pregnancy overweight was the most prevalent risk factor. Children of mothers in the risk group had higher birthweight and length. At the 7-year follow-up, they had a higher weight and BMI, and the odds ratio of being overweight was 3.0 (95% confidence interval 1.1-8.3). There was no group difference in the children's physical activity and their neurodevelopmental outcomes were similar. CONCLUSIONS: We found higher BMI and increased risk of overweight in children born to mothers with one or more risk factors for developing GDM. A focus on preventing pre-pregnancy overweight should be encouraged.

Systematic assessment of salivary inflammatory markers and dental caries in children: an exploratory study.

OBJECTIVE: To investigate associations between a wide panel of salivary inflammatory markers and the presence of dental caries among children. MATERIAL AND METHODS: In this exploratory, cross-sectional study, 176 children, aged 7-9, underwent a dental examination. Information on the children's oral health habits and lifestyles was collected from their mothers. In addition, saliva samples were collected and analyzed using a multiplex immunoassay. Of 92 inflammatory markers measured, 56 were included in the statistical analyses. To identify potential inflammatory markers associated with caries, we applied low to advanced statistical analyses. First, we performed traditional logistic regression analysis followed by Bonferroni corrections. Thereafter, a more robust and less conservative statistical approach, i.e. Least Absolute Shrinkage and Selection Operator (LASSO), was applied. The models were adjusted for potential confounders. RESULTS: Of the 176 children in the study, 22.2% were affected by caries. Among the 56 salivary inflammatory markers, only macrophage colony-stimulating factor 1 (CSF1) was selected by the LASSO and found to be positively associated with the presence of caries. CONCLUSIONS: The observed association between CSF1 and the presence of caries may be of clinical value in caries risk management and early diagnosis. Larger studies are warranted to assess the replicability of our findings.

Antenatal pelvic floor muscle training and urinary incontinence: a randomized controlled 7-year follow-up study.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence is common postpartum. Our aims were to assess whether antenatal exercise including pelvic floor muscle training (PFMT) has long-term effects on urinary incontinence (UI) and to explore factors associated with UI 7 years postpartum. METHODS: A follow-up of a two-centre randomized controlled trial performed at St. Olavs Hospital and Stavanger University Hospital, Norway. In the original trial women were randomized to a 12-week structured exercise protocol including PFMT or standard antenatal care during pregnancy. Link to an electronic questionnaire was sent by postal mail 7 years postpartum. Prevalence of UI was assessed with Sandvik severity index and compared between groups. Factors associated with UI were studied using multivariable logistic regression analysis. RESULTS: The response rate was 35% (298/855). UI was reported by 78 (51%) in the intervention group and 63 (57%) in the control group (p = 0.539). In the multivariable logistic regression analyses, women with UI at inclusion had a five-fold increase in odds of UI at 7 years (OR 5.4, 95% CI 2.6, 11.5). Engaging in regular exercise was not significantly associated with UI at 7 years; however, UI was associated with lower exercise intensity (OR 2.4, 95% CI 1.2, 4.6). CONCLUSIONS: We found no group differences of antenatal exercise including PFMT on UI after 7 years among the responders. UI in pregnancy increased the risk of long-term UI. Regular exercise was not associated with UI at 7 years; however, women with UI were more than twice as likely to exercise at lower intensity than continent women.

Treatment of urinary incontinence in women with chronic obstructive pulmonary disease-a randomised controlled study.

BACKGROUND: Little is known regarding treatment of urinary incontinence (UI) in women with chronic obstructive pulmonary disease (COPD). The aim of the study was to explore the efficacy of pelvic floor muscle training (PFMT) or cough-suppression techniques (CST) on UI in women with COPD. METHODS: A three-armed, two-centred, single-blinded, randomised controlled study was performed. Subjects were randomised to (a) PFMT for 16 weeks, (b) 2-3 educational sessions in CST, or (c) written information only. All participants completed questionnaires about UI, cough symptoms, and health status and underwent clinical examinations to evaluate the strength of the pelvic floor muscles and exercise capacity. Daily physical activity levels were measured using an activity monitor and lung function with spirometry. With a significance level of 5% and an 80% chance of detecting a significant difference between groups of 2.5 points on the ICIQ UI SF score, our sample size calculation showed that a total of 78 women, 26 in each group, was required to complete the study. RESULTS: During the period 2016 to 2018, 95 women were invited to the study. A total of 42 were recruited, three were excluded and 10 (24%) dropped out during the follow-up period. Mean ICIQ-UI SF total baseline score was 9.6 (range: 1-17) and 7.0 (range: 0-16) at follow-up. Changes in subjective UI as measured with the ICIQ-UI SF questionnaire were seen in the PFMT group and control group, but not in the CST group. CONCLUSION: Due to the low number of available participants and recruitment difficulties including practical issues such as travel distance, lack of interest, poor state of health, and high number of comorbidities, our results are inconclusive. However, reduced subjective UI was observed in the PFMT and control groups with a trend towards best effect in the PFMT group. Screening for UI is advisable in all women with COPD to be able to identify and treat these women to reduce symptom burden and improve quality of life. Future studies should focus on barriers to recruitment as well as randomised controlled studies with larger sample sizes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02614105. 25th November 2015.

Cytokine Patterns in Maternal Serum From First Trimester to Term and Beyond.

Pregnancy implies delicate immunological balance between two individuals, with constant changes and adaptions in response to maternal capacity and fetal demands. We performed cytokine profiling of 1149 longitudinal serum samples from 707 pregnant women to map immunological changes from first trimester to term and beyond. The serum levels of 22 cytokines and C-reactive protein (CRP) followed diverse but characteristic trajectories throughout pregnancy, consistent with staged immunological adaptions. Eotaxin showed a particularly robust decrease throughout pregnancy. A strong surge in cytokine levels developed when pregnancies progressed beyond term and the increase was amplified as labor approached. Maternal obesity, smoking and pregnancies with large fetuses showed sustained increase in distinct cytokines throughout pregnancy. Multiparous women had increased cytokine levels in the first trimester compared to nulliparous women with higher cytokine levels in the third trimester. Fetal sex affected first trimester cytokine levels with increased levels in pregnancies with a female fetus. These findings unravel important immunological dynamics of pregnancy, demonstrate how both maternal and fetal factors influence maternal systemic cytokines, and serve as a comprehensive reference for cytokine profiles in normal pregnancies.

Body mass index and physical activity in seven-year-old children whose mothers exercised during pregnancy: follow-up of a multicentre randomised controlled trial.

BACKGROUND: There are limited data on long-term outcomes of children whose mothers have followed exercise interventions during pregnancy. The aim of this paper was to investigate whether regular moderate intensity exercise during pregnancy affected the children's body mass index (BMI) and physical activity (PA) at 7 years of age, and determine the relationship between children's and mothers' BMI and PA. METHODS: This was a follow-up of a multicentre randomised controlled trial, carried out at St. Olavs Hospital, Trondheim University Hospital, and Stavanger University Hospital, Norway (2007-2009 and 2014-2016). Women were randomised to follow a 12-week structured exercise protocol or standard antenatal care during pregnancy. At the 7-year follow-up, parents reported their child's height, weight, and PA. The mothers also reported their own weight and PA. Main outcome variables were BMI, frequency and duration of moderate to vigorous PA (MVPA), and intensity of PA. RESULTS: A total of 855 women were randomised to exercise (n = 429) or standard antenatal care (n = 426) during pregnancy. At follow-up, 164 (38.2%) children and mothers in the intervention group and 117 (27.5%) in the control group participated. We found no group differences in the children's iso-BMI or PA. Findings were similar when we performed stratified analyses by sex, except boys in the control group spent more time on electrical devices than boys in the intervention group. Subgroup analyses of children of mothers who adhered to the exercise protocol and sensitivity analyses excluding children born preterm, children admitted to the neonatal intensive care unit, and children with diseases or health problems at the 7-year follow-up, did not change the results. Children's BMI, weekly leisure time MVPA and intensity of PA correlated with mothers' BMI, daily exercise, and intensity of exercise. CONCLUSIONS: Regular moderate intensity exercise during pregnancy did not affect BMI or PA of the children at 7 years. Good maternal health should be encouraged as it may influence the health of the next generation. TRIAL REGISTRATION: The initial RCT study was registered in ClinicalTrials.gov NCT00476567 .

Identifying women with gestational diabetes based on maternal characteristics: an analysis of four Norwegian prospective studies.

BACKGROUND: There is still no worldwide agreement on the best diagnostic thresholds to define gestational diabetes (GDM) or the optimal approach for identifying women with GDM. Should all pregnant women perform an oral glucose tolerance test (OGTT) or can easily available maternal characteristics, such as age, BMI and ethnicity, indicate which women to test? The aim of this study was to assess the prevalence of GDM by three diagnostic criteria and the predictive accuracy of commonly used risk factors. METHODS: We merged data from four Norwegian cohorts (2002-2013), encompassing 2981 women with complete results from a universally offered OGTT. Prevalences were estimated based on the following diagnostic criteria: 1999WHO (fasting plasma glucose (FPG) ≥7.0 or 2-h glucose ≥7.8 mmol/L), 2013WHO (FPG ≥5.1 or 2-h glucose ≥8.5 mmol/L), and 2017Norwegian (FPG ≥5.3 or 2-h glucose ≥9 mmol/L). Multiple logistic regression models examined associations between GDM and maternal factors. We applied the 2013WHO and 2017Norwegian criteria to evaluate the performance of different thresholds of age and BMI. RESULTS: The prevalence of GDM was 10.7, 16.9 and 10.3%, applying the 1999WHO, 2013WHO, and the 2017Norwegian criteria, respectively, but was higher for women with non-European background when compared to European women (14.5 vs 10.2%, 37.7 vs 13.8% and 27.0 vs 7.8%). While advancing age and elevated BMI increased the risk of GDM, no risk factors, isolated or in combination, could identify more than 80% of women with GDM by the latter two diagnostic criteria, unless at least 70-80% of women were offered an OGTT. Using the 2017Norwegian criteria, the combination "age≥25 years or BMI≥25 kg/m2" achieved the highest sensitivity (96.5%) with an OGTT required for 93% of European women. The predictive accuracy of risk factors for identifying GDM was even lower for non-European women. CONCLUSIONS: The prevalence of GDM was similar using the 1999WHO and 2017Norwegian criteria, but substantially higher with the 2013WHO criteria, in particular for ethnic non-European women. Using clinical risk factors such as age and BMI is a poor pre-diagnostic screening method, as this approach failed to identify a substantial proportion of women with GDM unless at least 70-80% were tested.

The effect of preoperative pelvic floor muscle training on urinary and colorectal-anal distress in women undergoing pelvic organ prolapse surgery-a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Pelvic floor muscle training (PFMT) improves urinary incontinence and mild pelvic organ prolapse (POP). We aimed to investigate the effect of preoperative PFMT on urinary and colorectal-anal distress and related quality of life (QoL) in women with severe POP scheduled for surgery. METHODS: Randomized controlled trial of 159 women scheduled for POP surgery (intervention = 81, controls = 78). Intervention consisted of daily PFMT from inclusion to the day of surgery. Symptoms and QoL were assessed at inclusion, day of surgery and 6 months postoperatively using the Urinary Distress Inventory (UDI-6), Colorectal-Anal Distress Inventory (CRADI-8), Urinary Impact Questionnaire (UIQ) and Colorectal-Anal Impact Questionnaire (CRAIQ) (range 0-100). Mixed model statistical analyses were used. RESULTS: One hundred fifty-one (95%) women completed the study (intervention = 75, controls = 76). Mean waiting times until surgery and follow-up were 22 and 28 weeks. There was no difference in mean postoperative symptom and QoL scores (95% CI) between the intervention and control group: UDI-6 16 (12-21) vs. 17 (13-22), CRADI-8 15 (11-18) vs. 13 (10-16), UIQ 11 (7-15) vs. 10 (6-13) and CRAIQ 5 (2-7) vs. 6 (4-9), all p > 0.05. Overall mean scores were reduced from baseline to postoperative follow-up: UDI-6 37 (33-41) vs. 17 (14-20), CRADI-8 22 (19-25) vs. 14 (11-16); UIQ 28 (24-32) vs. 10 (7-13) and CRAIQ 16 (12-19) vs. 5 (3-7), all p < 0.01. CONCLUSIONS: We found no added effect of preoperative PFMT on symptoms or QoL related to urinary and colorectal-anal distress in women scheduled for POP surgery. They achieved symptomatic improvement postoperatively regardless of PFMT. CLINICAL TRIAL REGISTRATION: The study was registered in clinicaltrials.gov: NCT 03,064,750.

Dietary Intake in Early Pregnancy and Glycemia in Late Pregnancy among Women with Obesity.

Women with obesity have increased risk for hyperglycemia during pregnancy, with negative health consequences for mother and child. We aimed to investigate adherence to nutritional recommendations in early pregnancy and to examine associations between early pregnancy dietary intake and late pregnancy glycemia among women with obesity. We included 120 women with pre-pregnancy body mass index (BMI) ≥30 kg/m2 who participated in one of two randomized controlled trials. The participants completed a food frequency questionnaire in early pregnancy (gestational weeks 12-22). Fasting and 120 min glucose tolerance after ingestion of 75 g glucose were assessed in late pregnancy (gestational weeks 32-37). About 90% of the participants reported early pregnancy diary intake within the recommendations. Average intakes of vitamin D, iron, and folate were below recommended levels. High intakes of dairy products and protein in early pregnancy were associated with lower fasting glucose in late pregnancy, whereas high intake of bread was associated with lower 120 min glucose. There were no clear associations between single dietary variables and gestational diabetes mellitus (GDM) diagnosis in late pregnancy. In conclusion, some early pregnancy dietary variables were associated with late pregnancy glycemia. Potential causality of these findings should be investigated in future studies.

Adverse events of exercise therapy in randomised controlled trials: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the relative risk (RR) of serious and non-serious adverse events in patients treated with exercise therapy compared with those in a non-exercising control group. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Primary studies were identified based on The Cochrane Database of Systematic Reviews investigating the effect of exercise therapy. ELIGIBILITY CRITERIA: At least two of the authors independently evaluated all identified reviews and primary studies. Randomised controlled trials were included if they compared any exercise therapy intervention with a non-exercising control. Two authors independently extracted data. The RR of serious and non-serious adverse events was estimated separately. RESULTS: 180 Cochrane reviews were included and from these, 773 primary studies were identified. Of these, 378 studies (n=38 368 participants) reported serious adverse events and 375 studies (n=38 517 participants) reported non-serious adverse events. We found no increase in risk of serious adverse events (RR=0.96 (95%CI 0.90 to 1.02, I2: 0.0%) due to exercise therapy. There was, however, an increase in non-serious adverse events (RR=1.19 (95%CI 1.09 to 1.30, I2: 0.0%). The number needed to treat for an additional harmful outcome for non-serious adverse events was 6 [95%CI 4 to 11). CONCLUSION: Participating in an exercise intervention increased the relative risk of non-serious adverse events, but not of serious adverse events. Exercise therapy may therefore be recommended as a relatively safe intervention.PROSPERO registration numberCRD42014014819.

The effect of an exercise program in pregnancy on vitamin D status among healthy, pregnant Norwegian women: a randomized controlled trial.

BACKGROUND: Vitamin D insufficiency is common in pregnant women worldwide. Regular prenatal exercise is considered beneficial for maternal and fetal health. There is a knowledge gap regarding the impact of prenatal exercise on maternal vitamin D levels. The objective of this study was to investigate whether a prenatal exercise program influenced serum levels of total, free and bioavailable 25-hydroxyvitamin D (25(OH)D) and related parameters. This is a post hoc analysis of a randomized controlled trial with gestational diabetes as the primary outcome. METHODS: Healthy, pregnant women from two Norwegian cities (Trondheim and Stavanger) were randomly assigned to a 12-week moderate-intensity exercise program (Borg perceived rating scale 13-14) or standard prenatal care. The intervention group (n = 429) underwent exercise at least three times weekly; one supervised group training and two home based sessions. The controls (n = 426) received standard prenatal care, and exercising was not denied. Training diaries and group training was used to promote compliance and evaluate adherence. Serum levels of 25(OH)D, parathyroid hormone, calcium, phosphate, magnesium and vitamin D-binding protein were measured before (18-22 weeks' gestation) and after the intervention (32-36 weeks' gestation). Free and bioavailable 25(OH)D concentrations were calculated. Regression analysis of covariance (ANCOVA) was applied to assess the effect of the training regime on each substance with pre-intervention levels as covariates. In a second model, we also adjusted for study site and sampling month. Intention-to-treat principle was used. RESULTS: A total of 724 women completed the study. No between-group difference in serum 25(OH)D and related parameters was identified by ANCOVA using baseline serum levels as covariates. The second model revealed a between-group difference in levels of 25(OH)D (1.9, 95% CI 0.0 to 3.8 nmol/L; p = 0.048), free 25(OH)D (0.55, 95% CI 0.10 to 0.99 pmol/L; p = 0.017) and bioavailable 25(OH)D (0.15 95% CI 0.01 to 0.29 nmol/L; p = 0.036). No serious adverse events related to regular exercise were seen. CONCLUSION: This study, a post hoc analysis, indicates that exercise may affect vitamin D status positively, and emphasizes that women with uncomplicated pregnancies should be encouraged to perform regular exercise. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00476567 , registered May 22, 2007.

The MMP9 rs17576 A>G polymorphism is associated with increased lumbopelvic pain-intensity in pregnant women.

BACKGROUND AND AIMS: Matrix metalloproteinase 9 (MMP9) is an enzyme that may affect degradation of several extracellular matrix (ECM) components in the pelvic ligaments during pregnancy. Previous studies indicate that genetic variations in the gene encoding MMP9 may affect the enzymatic activity. One such genetic variant is a single nucleotide polymorphism (SNP), rs17576 A>G. In this study we investigated whether the MMP9 SNP rs17576 A>G may be associated with increased lumbopelvic pain in 838 pregnant woman. The study was registered with ClinicalTrials.gov (NCT 00476567) on May 21, 2007. METHODS: Lumbopelvic pain-intensity was measured by visual analog scale (VAS) at two time points during pregnancy, T1 (18-22 weeks), T2 (32-36 weeks) and 3 months after delivery. Blood samples were collected at each point and SNP genotyping was carried out using predesigned TaqMan SNP genotyping assays. RESULTS: The results showed a significant association between the number of G alleles and pain-intensity in the evening at T2. The pain among G/G carriers was higher than among A/G carriers, which in turn was higher than among the A/A carriers. The most pronounced association between the G allele and pain-intensity was observed in primiparae. CONCLUSIONS: We conclude that the MMP9 rs17576 A>G polymorphism is associated with increased lumbopelvic pain-intensity during pregnancy. The present data support the hypothesis that lumbopelvic pain during pregnancy may be related to a relaxin - MMP9 - tissue remodeling mechanism. IMPLICATIONS: The present findings may be important for future mechanistic studies on how MMP9 rs17576 A>G may affect changes in the ECM components in pelvic ligaments and lumbopelvic pain-intensity during pregnancy.

Alterations in the vitamin D endocrine system during pregnancy: A longitudinal study of 855 healthy Norwegian women.

To ensure optimal calcium accrual in the fetal skeleton, a substantial rise occurs in 1,25-dihydroxyvitamin D (1,25(OH)2D), but is dependent on sufficient 25-hydroxyvitamin (25(OH)D). Large longitudinal studies addressing free 25(OH)D and 1,25(OH)2D during pregnancy are scarce. We aimed to assess levels of and relationship between 25(OH)D, 1,25(OH)2D, vitamin D-binding protein (DBP), parathyroid hormone (PTH), and free 25(OH)D during pregnancy; determinants of vitamin D status; and association between vitamin D indices or PTH and pregnancy outcomes (gestational diabetes mellitus and birthweight). Altogether 855 pregnant Norwegian Caucasian women from Trondheim and Stavanger (latitude 63°N and 58°N) were recruited; 94 were lost to follow-up. The study was originally a randomized controlled trial (2007-2009) with gestational diabetes as primary outcome. Data were collected in second and third trimester. In third trimester, 246 (34%) had vitamin D insufficiency and 52 (7%) deficiency (25(OH)D <50 and <30nmol/L, respectively). During wintertime in third trimester, 61 (47%) from Trondheim and 23 (51%) from Stavanger exhibited vitamin D insufficiency. PTH was elevated in 27 (3.7%). Estimate of change between trimesters was (95% CI): 25(OH)D -1.8 (-2.8 to -0.7) nmol/L, DBP 0.62 (0.57 to 0.66) µmol/L, calculated free 25(OH)D -1.7 (-2.0 to -1.4) pmol/L, PTH 0.81 (0.72 to 0.90) pmol/L, 1,25(OH)2D (sub-analysis) 31.4 (CI 24.7 to 38.2) pmol/L. A decrease in 1,25(OH)2D occurred in 45% of those with vitamin D deficiency, and they also exhibited lower levels than women with adequate vitamin D status. No association of vitamin D indices and PTH with pregnancy outcomes was observed. Women in Trondheim displayed lower 25(OH)D levels, despite minor latitudinal differences. Less than one-fifth adhered to the authorities' vitamin D recommendations. These findings demonstrate that hypovitaminosis D is prevalent among pregnant women living in northern latitudes, especially during the dark season, and there is an unmet need to ensure adequate vitamin D intake.

Prevalence and predictors of double incontinence 1 year after first delivery.

INTRODUCTION AND HYPOTHESIS: Urinary (UI) and anal incontinence (AI) are common pelvic floor disorders (PFD), and postpartum women experiencing double incontinence (DI), the combination of UI and AI, tend to have more severe symptoms and a greater impact on quality of life. Our objective was to investigate the prevalence and predictors of postpartum DI and UI alone 1 year after first delivery. METHODS: In this prospective cohort study, 976 women reported the prevalence of DI and UI alone 1 year after their first delivery in one of two hospitals in Norway using the St Marks score and the ICI-Q UI SF. RESULTS: DI was significantly reduced from 13% in late pregnancy to 8% 1 year later, whereas 30% reported UI at both time points. Incontinence in late pregnancy predicted incontinence 1 year after delivery. Higher age was associated with UI alone. Compared with caesarean delivery, normal vaginal or instrumental delivery increased the risk of UI alone more than three and four times respectively. Obstetric anal sphincter injuries showed a four-fold increase in the risk of DI. CONCLUSIONS: Nearly 50% reported incontinence symptoms 1 year after first delivery. Continence status during pregnancy was one of the main predictors of postpartum continence status. Mode of delivery increased the risk of postpartum UI, whereas obstetric anal sphincter injuries increased the risk of postpartum DI.