Does 17-α-hydroxyprogesterone caproate affect fetal biometry and birth weight in twin pregnancy?

OBJECTIVE: Increasingly, maternal administration of 17-α-hydroxyprogesterone caproate (17-OHPC) is utilized to prevent preterm birth, but the fetal safety of 17-OHPC is still a matter of concern. This study aimed to assess whether exposure to 17-OHPC during the second and third trimesters of pregnancy affects fetal biometry in twin gestations. METHODS: This study included a subset of women with a twin pregnancy who had been previously included in a randomized clinical trial comparing the effectiveness of 17-OHPC and placebo on neonatal outcomes and preterm birth rates in multiple pregnancy. In the present study, the individual growth patterns of femur length, head circumference and abdominal circumference were compared between fetuses of women who had been randomized to receive weekly injections of either 17-OHPC (n = 52) or placebo (n = 58) at between 16-20 and 36 weeks' gestation. RESULTS: The three biometric variables assessed developed similarly in fetuses in both the group exposed to 17-OHPC and the placebo group during the second half of pregnancy. Birth weight adjusted for parity and fetal sex was also comparable between groups. CONCLUSION: The use of 17-OHPC has no adverse effects on fetal biometry and birth weight in twins.

Carbetocin in comparison with oxytocin in several dosing regimens for the prevention of uterine atony after elective caesarean section in the Netherlands.

PURPOSE: The aim of the study was to compare the prophylactic effects of carbetocin with those of oxytocin for the prevention of uterine atony in patients undergoing elective caesarean section (CS) in the Netherlands. The primary endpoint was the need for additional uterotonic medication. METHODS: Each of the five participating Dutch hospitals treated 50-100 term patients with 100 µg of intravenous carbetocin on prescription. Each centre retrieved charts of 250 patients treated with oxytocin according to the hospital's policy for the prevention of uterine atony (oxytocin bolus 5 IU, bolus 10 IU or bolus 5 IU followed by 10 IU in 2 h). RESULTS: In the carbetocin group 462 subjects were included and in the oxytocin group 1,122. The proportion of subjects needing additional uterotonic treatment was 3.1 % (95 % CI 1.7-5.1 %) after carbetocin and 7.2 % (5.8-8.9 %) after oxytocin; relative risk 0.41 (0.19-0.85); p = 0.0110. Carbetocin was most effective compared with the oxytocin 5 IU bolus subgroup with less need for additional uterotonic medication (3.1 vs. 9.3 %, p = 0.0067) and blood transfusions (2.2 vs. 3.6 %, p = 0.0357). CONCLUSIONS: Compared with oxytocin, prophylaxis of uterine atony with carbetocin after an elective CS diminished the need for additional uterotonics by more than 50 %.

Effect of 17-alpha hydroxyprogesterone caproate on cervical length in twin pregnancies.

OBJECTIVES: Previous studies on singleton pregnancies have indicated that progestogens may reduce the rate of cervical shortening during pregnancy. The aim of this study was to investigate whether treatment with 17-alpha hydroxyprogesterone caproate (17-OHPC) has an effect on cervical shortening in twin pregnancies. METHODS: This was a secondary analysis of patients who had participated in a multicenter randomized clinical trial on the effectiveness of 17-OHPC in preventing preterm birth in multiple pregnancies (the AMPHIA-trial). We included all trial participants with a twin gestation who had undergone repeat cervical length measurements during pregnancy. We performed a separate analysis of women with repeat measurements in centers where this was standard protocol for multiple pregnancies. The rate of cervical shortening for both the 17-OHPC group and the placebo group was analyzed using a linear mixed model. RESULTS: Of the 671 patients who participated in the trial, 282 (42%) had a twin pregnancy and underwent two or more cervical length measurements. Of these women, 140 were monitored in centers where repeat measurements were standard protocol. We observed an overall reduction of cervical length from 44.3 mm at 14-18 weeks to 30.0 mm at 30-34 weeks' gestation. In the 17-OHPC group, cervical length decreased by 1.04 mm each gestational week, while this was 1.11 mm per week for the placebo group (P = 0.6). For the overall group, each 10% decrease in cervical length led to an increase in the risk of preterm birth (hazard ratio, 1.14; 95% CI, 1.08-1.21). CONCLUSION: In women with a twin pregnancy, there is progressive shortening of the cervix during pregnancy, regardless of 17-OHPC use.

Postnatal growth of preterm born children ≤ 750g at birth.

BACKGROUND: Extremely low birth weight (ELBW) infants are at risk of impaired postnatal growth. Impaired postnatal growth has been reported to be associated with delayed cognitive and motor development. AIMS: To describe postnatal growth patterns of appropriate and small for gestational age (AGA and SGA) ELBW children in relation to their cognitive and motor outcome at age 5.5. STUDY DESIGN: Retrospective cohort study. SUBJECTS: One hundred one children with a BW ≤ 750g, born between 1996 and 2005 in the University Hospital Utrecht, The Netherlands. OUTCOME MEASURES: Height (Ht), weight (Wt), occipital-frontal circumference (OFC) at birth, 15 months and 2 years corrected age and 3.5 and 5.5 years. Cognitive and motor outcome at 5.5 years of age, classified as normal (Z-score ≥-1), mildly delayed (-2≤Z-score <-1) or severely delayed (Z-score <-2). AGA (Ht, Wt or OFC at birth ≥-2 SDS) infants were compared with SGA (Ht, Wt or OFC at birth <-2 SDS) infants. RESULTS: Between birth and 5.5 years catch-up growth in Ht, weight for height (Wt/Ht), Wt and OFC was seen in 72.2%, 55.2%, 28.6% and 68.9% respectively of the SGA infants. For AGA infants we found substantial catch-down growth in Ht (15.4%) and Wt (33.8%). Cognitive and motor outcome was normal in 76.2% and 41.6% of the 101 children. A significantly higher percentage of normal cognitive outcome was found in AGA infants with Wt growth remaining at ≥-2 SDS compared to AGA infants with catch-down growth (83% vs 63%). Next, SGA infants who caught-up in OFC had a higher prevalence of normal cognitive outcome compared to SGA infants who did not catch-up in OFC. Furthermore, a higher percentage of severely delayed motor outcome was found in SGA infants without catch-up growth in Wt compared to SGA infants who caught-up in Wt (61.5% vs 32.2%). CONCLUSIONS: Catch-up growth in Ht, Wt/Ht and OFC occurred in the majority of the SGA infants with a BW ≤ 750 g, but was less common in Wt. AGA children who remained their Wt at ≥-2 SDS have a better cognitive and motor developmental outcome at 5.5 years of age. Catch-up growth in OFC was associated with a better cognitive outcome at 5.5 years of age.

Cervical length measurement for the prediction of preterm birth in multiple pregnancies: a systematic review and bivariate meta-analysis.

OBJECTIVES: To review the literature on cervical length as a predictor of preterm birth in asymptomatic women with a multiple pregnancy. METHODS: We searched MEDLINE, Embase and reference lists of included articles to identify all studies that reported on the accuracy of cervical length for predicting preterm birth in asymptomatic women with a multiple pregnancy. We scored study characteristics and study quality, and extracted data in order to construct two-by-two tables cross-classifying cervical length and preterm delivery. Meta-analysis using a bivariate model was performed. Summary receiver-operating characteristics (ROC) curves were generated for various test characteristics and outcome definitions. RESULTS: We found 21 studies reporting on 2757 women. There was a large variation in gestational age at measurement, cut-off point for cervical length and definition of preterm birth. The summary ROC curve indicated a good predictive capacity of short cervical length for preterm birth. Summary estimates of sensitivity and specificity for preterm birth before 34 weeks' gestation were 78% and 66%, respectively, for 35 mm, 41% and 87% for 30 mm, 36% and 94% for 25 mm and 30% and 94% for 20 mm. CONCLUSIONS: In women with a multiple pregnancy, second-trimester cervical length is a strong predictor of preterm birth. In the absence of effective preventive strategies, there is currently no place in clinical practice for cervical length measurement in this population. However, future studies should evaluate preventive interventions in women with multiple pregnancies and a short cervix, and cervical length should be measured in any trial studying preventive strategies in multiple pregnancies.

Neurodevelopmental outcome over time of preterm born children ≤750 g at birth.

BACKGROUND: Extremely low birth weight (ELBW) infants are at risk of cognitive impairment and follow-up is therefore of major importance. The age at which their neurodevelopmental outcome (NDO) can reliably be predicted differs in the literature. AIMS: To describe NDO at 2, 3.5 and 5.5 years in an ELBW cohort. To examine the value of NDO at 2 years corrected age (CA) for prediction of NDO at 3.5 and 5.5 years. STUDY DESIGN: A retrospective cross-sectional and longitudinal cohort study. SUBJECTS: 101 children with a BW≤750 g, born between 1996 and 2005, who survived NICU admission and were included in a follow-up program. OUTCOME MEASURES: NDO, measured with different tests for general development and intelligence, depending on age of assessment and classified as normal (Z-score≥-1), mildly delayed (-2≤Z-score<-1) or severely delayed (Z-score<-2). RESULTS: At 2, 3.5 and 5.5 years 74.3, 82.2 and 76.2% had a normal NDO. A normal NDO at 2 years CA predicted a normal NDO at 3.5 and 5.5 years in 92% and 84% respectively. Of the children with a mildly or severely delayed NDO at 2 years CA the majority showed an improved NDO at 3.5 (69.2%) and 5.5 years (65.4%) respectively. CONCLUSIONS: The majority of the children with a BW≤750 g had a normal NDO at all ages. A normal NDO at 2 years CA is a good predictor for normal outcome at 3.5 and 5.5 years, whereas a delayed NDO at 2 years CA is subject to change with the majority of the children showing a better NDO at 3.5 and 5.5 years.

Two-year neurodevelopmental outcome of preterm born children ≤ 750 g at birth.

OBJECTIVES: To describe 2-year neurodevelopmental outcome (NDO) in a cohort of extremely low birthweight infants, and compare NDO between two consecutive 5-year periods and between appropriate (AGA, ≥p10) and small for gestational age (SGA, -1 Z score ≤-2) or severely delayed (Z score >-2). RESULTS: 74.3% of the children had a normal NDO at 2 years corrected age, 20.8% a mildly and 5% a severely delayed outcome. Although survival significantly increased with time (65.8% to 88.1%, p=0.002), significantly fewer children in cohort II (66.1% vs 84.4% in cohort I, p=0.042) as well as fewer SGA children (64.3% vs 86.7% of AGA children, p=0.012) had a normal NDO. CONCLUSIONS: Increased survival of infants with a birth weight ≤750 g coincided with more children with an impaired NDO at 2 years corrected age. SGA infants are especially at risk of impaired NDO.

Case report: a black and white twin.

Albinism is an autosomal recessive disorder that is caused by a defective synthesis of melanin, resulting in a generalized reduction of pigmentation in the skin, hair and eyes, and leading to an increased risk of skin cancer and vision problems. We report a case of a 22-year-old primigravida of Negroid origin who delivered dichorial diamniotic twins: two daughters were born with a totally different appearance. The first child had a light brown skin, black curly hair and brown eyes, whereas the second had a striking white skin, red-blond curly hair and blue eyes. Oculocutaneous albinism (OCA) and heteropaternal superfecundation were considered in the differential diagnosis. Genetic testing confirmed the diagnosis of OCA type 2 in the second child. The diagnosis of albinism has clinical implications and must be considered when a black and white twin is born.

Changes in survival and neonatal morbidity in infants with a birth weight of 750 g or less.

BACKGROUND: Improvement in perinatal and neonatal care has resulted in increased survival of extremely low birth weight (ELBW) infants. OBJECTIVES: To describe survival and neonatal morbidity in a cohort of ELBW infants, to compare two consecutive 5-year periods, and compare appropriate (AGA) with small for gestational age (SGA) infants (AGA ≥p10, and SGA

Risk factors for uterine rupture during a vaginal birth after one previous caesarean section: a case-control study.

OBJECTIVE: To study risk factors for uterine rupture (UR) in women with one previous caesarean section (CS) undergoing a vaginal birth after CS (VBAC). STUDY DESIGN: A nested case-control study was conducted. Baseline characteristics, general obstetric history, details of the previous CS, current delivery and maternal and neonatal outcome were analysed for 41 cases with a UR and 157 controls (no rupture). Data were extracted from 21 Dutch hospitals. RESULTS: Labour induction was more common in cases than in controls (51% vs. 25% respectively, P=0.001), and in case of induction therapy especially the use of prostaglandins (PGE2) was more frequent in the case group (86% vs. 46%, P=0.014 for cases and controls respectively). Patients with UR had a significantly lower Bishop score (median: 2.0 vs. 4.0, P=0.005) and received more augmentation of labour compared to controls (36% vs. 18%, P=0.010). In the multivariate analysis induction with PGE2 and oxytocin, induction with PGE2 alone, and augmentation of labour were independent variables affecting the occurrence of UR (respectively OR 13.0, CI 2.3-74.2; OR 4.6, CI 1.9-11.3 and OR 2.7, CI 1.2-6.3). Forty-four percent of the ruptures can be explained by induction of labour with prostaglandins+/-oxytocin. CONCLUSION: Having studied baseline characteristics, general obstetric history, details of the previous CS and of the current delivery, we show that no factors other than the use of PGE2 (+/-oxytocin) in response to a low Bishop score, and augmentation of labour with oxytocin are associated with an increased risk for UR in women undergoing VBAC after one previous CS.

Prediction of fetal lung immaturity using gestational age, patient characteristics and fetal lung maturity tests: a probabilistic approach.

OBJECTIVES: The lecithin/sphingomyelin (L/S) ratio and the lamellar body count (LBC) can be used to predict respiratory distress syndrome (RDS). DESIGN: We performed a retrospective cohort study among consecutive women who underwent amniotic fluid sampling for the assessment of fetal lung maturity. Logistic regression was used to construct models for the prediction of RDS in three gestational age categories, with models based on clinical characteristics only, clinical characteristics and the LBC, and on clinical characteristics and L/S ratio. RESULTS: When amniotic fluid was collected <30 weeks, the specificity of the LBC was 30% and the sensitivity 100%. Addition of the L/S ratio increased the specifity to 60%, for a sensitivity of 100%. When amniocentesis was performed between 30 and 33 weeks, addition of the L/S ratio only marginally improved the performance of the LBC. CONCLUSIONS: At a gestational age <30 weeks, the L/S ratio has additional value over the LBC. Above 30 weeks of gestation, single use of the LBC seems sufficient.

Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery.

OBJECTIVE: To determine the risk factors for anal sphincter injuries during operative vaginal delivery. SETTING AND DESIGN: A population-based observational study. POPULATION: All 21 254 women delivered with vacuum extraction and 7478 women delivered with forceps, derived from the previously validated Dutch National Obstetric Database from the years 1994 to 1995. METHODS: Anal sphincter injury was defined as any injury, partial or complete, of the anal sphincters. Risk factors were determined with multivariate logistic regression analysis. MAIN OUTCOME MEASURES: Individual obstetric factors, e.g. fetal birthweights, duration of second stage, etc. RESULTS: Anal sphincter injury occurred in 3.0% of vacuum extractions and in 4.7% of forceps deliveries. Primiparity, occipitoposterior position and fetal birthweight were associated with an increased risk for anal sphincter injury in both types of operative vaginal delivery, whereas duration of second stage was associated with an increased risk only in vacuum extractions. Mediolateral episiotomy protected significantly for anal sphincter damage in both vacuum extraction (OR 0.11, 95% CI 0.09-0.13) and forceps delivery (OR 0.08, 95% CI 0.07-0.11). The number of mediolateral episiotomies needed to prevent one sphincter injury in vacuum extractions was 12, whereas 5 mediolateral episiotomies could prevent one sphincter injury in forceps deliveries. CONCLUSIONS: Primiparity and occipitoposterior presentation are strong risk factors for the occurrence of anal sphincter injury during operative vaginal delivery. The highly significant protective effect of mediolateral episiotomies in both types of operative vaginal delivery warrants the conclusions that this type of episiotomy should be used routinely during these interventions to protect the anal sphincters.

Is there an association between depressive and urinary symptoms during and after pregnancy?

Depressive symptoms and urinary symptoms are both highly prevalent in pregnancy. In the general population, an association is reported between urinary symptoms and depressive symptoms. The association of depressive and urinary symptoms has not yet been assessed in pregnancy. In this study, we assessed (1) the prevalence of depressive symptoms, over-active bladder (OAB) syndrome, urge urinary incontinence (UUI) and stress urinary incontinence (SUI) during and after pregnancy using the Center for Epidemiologic Studies Depression Scale (CES-D) and the Urogenital Distress Inventory (UDI) and (2) the association of depressive symptoms with urinary incontinence and over-active bladder syndrome during and after pregnancy, controlling for confounding socioeconomic, psychosocial, behavioural and biomedical factors in a cohort of healthy nulliparous women. Our data show a significant increase in prevalence of depressive symptoms, UUI, SUI and OAB during pregnancy and a significant reduction in prevalence of depressive symptoms, SUI and OAB after childbirth. UUI prevalence did not significantly decrease after childbirth. In univariate analysis, urinary incontinence and the OAB syndrome were significantly associated with a CES-D score indicative of a possible clinical depression at 36 weeks gestation. However, after adjusting for possible confounding factors, only the OAB syndrome remained significantly associated (OR 4.4 [1.8-10.5]). No association was found between depressive and urinary symptoms at 1 year post-partum. Only OAB was independently associated with depressive symptoms during pregnancy. Possible explanations for this association are discussed.

Trends in obstetric interventions in the Dutch obstetrical care system in the period 1993-2002.

OBJECTIVE: To determine trends in induction of labour-, instrumental vaginal delivery- and caesarean section rates in the Netherlands in the period 1993-2002. STUDY DESIGN: Data derived from The Netherlands Perinatal Registry and Statistics Netherlands were used to calculate annual rates for induction of labour, instrumental vaginal delivery and caesarean section. Regarding caesarean section, rates were also calculated for different subgroups with respect to parity, presentation of the fetus, gestational age and multiple pregnancies. In the subgroup of women with a singleton fetus in vertex presentation between 37 and 42 weeks of gestation instrumental delivery rates were compared for women with induced labours and women in spontaneous labour. RESULTS: The overall CS rate rose from 8.1 to 13.6%. Proportionally the rise was greatest for breech presentation (+37.7%), multiple gestations (+12.7%) and women delivering between 24 and 28 weeks (+9.5%). However, in absolute numbers the rise was most impressive in the group of women with a singleton fetus in vertex presentation between 37 and 42 weeks of gestation. Rate of induction of labour and instrumental vaginal delivery remained constant (approximately 15% respectively 10% of all deliveries). In nulliparous term women with singletons in vertex presentation the CS rate increased with 8.0% to a rate of 20.7% when labour was induced versus an increase of 3.4% to a rate of 7.5% in spontaneous labour. CONCLUSION: In absolute numbers the rise in CS was most extensive in the group of women with a singleton fetus in vertex presentation between 37 and 42 weeks of gestation. Induction of labour rates and instrumental vaginal delivery rates remained constant during the past decade.

Acute activation of the endothelium results in increased levels of active von Willebrand factor in hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome.

BACKGROUND: HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome is a severe complication of pre-eclampsia in pregnancy, characterized by microvascular platelet thrombi. Activation of the endothelium is thought to play a key role in pre-eclampsia and HELLP syndrome. Activation of endothelial cells may lead to release of von Willebrand factor (VWF) multimers, which are highly reactive with platelets. Normally, newly released multimers are cleaved by ADAMTS13, resulting in less reactive derivatives. OBJECTIVE: We hypothesized that HELLP syndrome is characterized by increased amounts of active VWF compared with healthy pregnancy and pre-eclampsia, due to acute activation of endothelial cells. This might contribute to thrombocytopenia and thrombotic microangiopathy. METHODS: Active VWF and ADAMTS13 activity were measured in healthy pregnant volunteers (n = 9), patients with pre-eclampsia (n = 6) and patients with HELLP syndrome (n = 14) at similar gestational ages. To study the role of endothelial cell activation, the propeptide/mature VWF ratio was determined, and VWF released by cultured endothelial cells was analyzed. RESULTS: Active VWF levels were increased 2.1-fold in HELLP syndrome compared with healthy pregnant volunteers (P < 0.001) and 1.6-fold compared with patients with pre-eclampsia (P = 0.001). ADAMTS13 activity was moderately decreased in patients with HELLP syndrome compared with healthy pregnant volunteers (P < 0.004), but not compared with patients with pre-eclampsia. The propeptide/mature VWF ratio was increased 1.7-fold compared with healthy pregnant volunteers (P < 0.001) and 1.5-fold compared with patients with pre-eclampsia (P < 0.05). A significant correlation was found between this ratio and the activation factor of VWF (r = 0.68, P < 0.001). The amount of active VWF was increased 1.4-fold in medium of stimulated endothelial cells when compared with non-stimulated cells (P < 0.05). CONCLUSION: Acute endothelial cell activation in HELLP syndrome and decreased ADAMTS13 activity result in increased amounts of active VWF. This might explain the consumptive thrombocytopenia and thrombotic microangiopathy associated with HELLP syndrome. Inhibition of circulating active VWF could be a potential new approach in the treatment of patients with HELLP syndrome.

Which factors determine the sexual function 1 year after childbirth?

OBJECTIVE: To evaluate which factors determine sexual activity and satisfaction with the sexual relationship 1 year after the first delivery. DESIGN: Prospective longitudinal cohort study. SETTING: Ten midwifery practices. POPULATION: Three hundred and seventy-seven nulliparous women were included. METHODS: The Maudsley Marital Questionnaire is a standardised and validated questionnaire with 15 items relating to marital and sexual adjustment, with a nine-point (0-8) scale appended to each question. Scores on the sexual scale (MMQ-S) range from 0 to 40. Higher scores are indicative of greater dissatisfaction. Sexual intercourse was dichotomised into having sexual intercourse or not having sexual intercourse. Several obstetric and maternal factors were analysed. MAIN OUTCOME MEASUREMENTS: Sexual intercourse at 1 year postpartum and dissatisfaction with the sexual relationship as assessed by the MMQ-S scale. RESULTS: In multiple logistic regression analysis, the main predictive factor for no sexual intercourse 1 year postpartum was no sexual intercourse at 12 weeks of gestation (beta 11.0 [4.01-30.4]). Women were five times less likely to be sexually active after a third/fourth degree anal sphincter tear as compared with women with an intact perineum (beta 0.2 [0.04-0.93]). Dissatisfaction with the sexual relationship 1 year after childbirth, assessed with the MMQ-S scale, is associated with not being sexually active at 12 weeks of gestation (beta- 0.208, P= 0.004) and with an older maternal age at delivery (beta 0.405, P= 0.032). CONCLUSION: An important prognostic factor for dissatisfaction with the sexual relationship 1 year postpartum was not being sexually active in early pregnancy. Satisfaction with the sexual relationship seems not to depend on pregnancy- and parturition-associated factors.

The Pregnancy Mobility Index: a mobility scale during and after pregnancy.

BACKGROUND: During pregnancy, every second woman will experience some degree of back or pelvic pain. While several validated instruments to assess back pain exist for the general population, these are not suitable for application in a pregnant population and have not been validated for this purpose. A pregnant population not only differs from the general population regarding the type of back pain--frequently a pelvic girdle component is added--but pregnant women also have different mobility patterns and expectations. We therefore present in this study a self-report mobility scale specifically designed for a pregnant population: the Pregnancy Mobility Index. METHODS: Longitudinal cohort study including 672 nulliparous women with a singleton low-risk pregnancy. The Pregnancy Mobility Index consists of items concerning day-to-day activities selected through literature research and clinical experience. Participating women completed the questionnaire at 12 and 36 weeks' gestation and one year after delivery. Reliability, construct and criterion validity were tested. RESULTS: The internal consistency (Cronbach's alpha) was 0.8 or higher. The Pregnancy Mobility Index scales correlated best with the physical and pain scale of the RAND-36, indicating a good construct validity. The assumptions that the Pregnancy Mobility Index scores increase during pregnancy and decrease after delivery and that women with back or pelvic problems scored higher on the Pregnancy Mobility Index domains than women without back or pelvic pain were confirmed, indicating a good criterion validation. CONCLUSION: The Pregnancy Mobility Index has been shown to be a reliable and valid questionnaire well suited for use during and after pregnancy.

[Pregnancy complications as a risk factor for metabolic and cardiovascular disease in later life]. / Zwangerschapscomplicaties als risicofactor voor metabole en cardiovasculaire aandoeningen op latere leeftijd.

In recent years several large epidemiological studies have been published that demonstrate that women who experience gestational diabetes, pregnancy-induced hypertension or pre-eclampsia have an increased risk of developing type-2 diabetes mellitus and cardiovascular disease. 15-50% of women who experience gestational diabetes develop type-2 diabetes mellitus; the risk is particularly high in those who require insulin therapy during pregnancy. - Chronic hypertension frequently develops years after a pregnancy complicated by pregnancy-induced hypertension, especially in women who have had pregnancy-induced hypertension in multiple pregnancies. Women who experience pre-eclampsia in the first 36 weeks of pregnancy or in multiple pregnancies have an increased risk of cardiovascular morbidity and mortality in later life. Therefore gestational diabetes, pregnancy-induced hypertension and pre-eclampsia provide an opportunity to identify individuals with an increased risk of type-2 diabetes mellitus and cardiovascular disease at an early age. This may create new perspectives on prevention.

Psychosocial factors and mode of delivery.

Childbirth is a substantial physical and emotional endeavor. Because emergency Cesarean and instrumental vaginal delivery impose a greater mortality and physical and emotional morbidity on both the mother and the infant than normal vaginal delivery, it is important to identify factors that are associated with the risk of operative delivery. In previous investigations, some associations have been found, but the effect of psychosocial factors is not clear. In this study we examined several factors which could be associated with the risk for instrumental and surgical delivery. In addition to biomedical factors we included psychosocial factors such as depressive symptoms, quality of the relationship of the woman with her partner, personality, lifestyle and educational level. We assessed 354 healthy nulliparous pregnant women with a child in vertex presentation and spontaneous onset of term labor using validated questionnaires. We found that social support from the woman's partner in pregnancy, lack of depressive symptoms and specific personality traits are not protective against instrumentally assisted vaginal delivery or emergency Cesarean section. Predictive factors for operative delivery after spontaneous onset of labor are higher fetal weight, non-occiput anterior presentation and advanced gestational age, and foremost fetal distress during parturition.