Importance of antenatal identification of small for gestational age fetuses on perinatal and childhood outcomes: A register-based cohort study.

INTRODUCTION: Fetal growth restriction (FGR) is associated with increased risk for stillbirth, perinatal morbidity, cerebral palsy, neurodevelopmental disorders and cardiovascular disease later in life. Identifying small-for-gestational-age (SGA) fetuses is crucial for the diagnosis of FGR. The aim of this study was to investigate the association between antenatal identification of SGA fetuses and severe adverse perinatal and childhood outcome. MATERIAL AND METHODS: A register-based cohort study of all newborns delivered in Stockholm in 2014 and 2017. INCLUSION CRITERIA: singleton pregnancies without chromosomal aberrations or structural abnormalities, with a gestational age at delivery between 22+0 and 43+0 (n = 48 843). Data from childbirth records were linked to data from nationwide Swedish registers. Pregnancy including offspring data were reviewed. Adverse outcomes for non-identified and identified SGA newborns were compared using logistic regression models. Primary outcome was a composite outcome called severe adverse outcome, defined as at least one of the following: stillbirth, severe newborn distress (Apgar score <4 at 5 min, pH <7 or resuscitation activities >10 min), severe neonatal outcome (hypoxic ischemic encephalopathy 2-3, necrotizing enterocolitis, neonatal seizures, intraventricular hemorrhage grade 3-4, bronchopulmonary disease or death at <1 year), severe childhood outcome (cognitive impairment or motor impairment or cerebral palsy or hearing impairment or visual impairment or death at 1-3 years old). Secondary outcomes were stillbirth, severe newborn distress, severe neonatal outcome, severe childhood outcome. RESULTS: No association was found between antenatal identification of SGA fetuses and severe adverse outcome using the complete composite outcome (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 0.93-1.53). In subgroup analyses, non-identified SGA fetuses had an almost fivefold increased risk for stillbirth (aOR 4.79, 95% CI 2.63-8.72) and an increased risk for severe newborn distress (aOR 1.36, 95% CI 1.02-1.82), but a decreased risk for severe childhood outcome (aOR 0.63, 95% CI 0.40-0.99). No association was found between antenatal identification of SGA and severe neonatal outcome. CONCLUSIONS: Non-identified SGA fetuses have an increased risk for stillbirth and severe newborn distress. Conversely, identified SGA fetuses have an increased risk for severe childhood outcome.

Pre-pregnancy complications - associated factors and wellbeing in early pregnancy: a Swedish cohort study.

BACKGROUND: Many couples experience difficulties to become pregnant or carry a pregnancy to term due to unknown causes. Here we define pre-pregnancy complications as having prior recurrent pregnancy loss, prior late miscarriages, time to pregnancy more than one year, or the use of artificial reproductive technologies. We aim to identify factors associated with pre-pregnancy complications and poor well-being in early pregnancy. METHODS: Online questionnaire data from 5330 unique pregnancies in Sweden were collected from November 2017 - February 2021. Multivariable logistic regression modelling was used to investigate potential risk factors for pre-pregnancy complications and differences in early pregnancy symptoms. RESULTS: Pre-pregnancy complications were identified in 1142 participants (21%). Risk factors included diagnosed endometriosis, thyroid medication, opioids and other strong pain medication, body mass index > 25 kg/m2 and age over 35 years. Different subgroups of pre-pregnancy complications had unique risk factors. The groups also experienced different pregnancy symptoms in early pregnancy, where women that had experienced recurrent pregnancy loss were at higher risk of depression in their current pregnancy. CONCLUSION: We report one of the largest pregnancy cohorts with high frequency of pre-pregnancy complications compared to the Swedish population. Prescribed drug use and body weight were the top potentially modifiable risk factors in all groups. Participants that experienced pre-pregnancy complications also had higher risk of depression and pregnancy problems in early pregnancy.

No evidence for a placental microbiome in human pregnancies at term.

BACKGROUND: The placenta plays an important role in the modulation of pregnancy immunity; however, there is no consensus regarding the existence of a placental microbiome in healthy full-term pregnancies. OBJECTIVE: This study aimed to investigate the existence and origin of a placental microbiome. STUDY DESIGN: A cross-sectional study comparing samples (3 layers of placental tissue, amniotic fluid, vernix caseosa, and saliva, vaginal, and rectal samples) from 2 groups of full-term births: 50 women not in labor with elective cesarean deliveries and 26 with vaginal deliveries. The comparisons were performed using polymerase chain reaction amplification and DNA sequencing techniques and bacterial culture experiments. RESULTS: There were no significant differences regarding background characteristics between women who delivered by elective cesarean and those who delivered vaginally. Quantitative measurements of bacterial content in all 3 placental layers (quantitative polymerase chain reaction of the 16S ribosomal RNA gene) did not show any significant difference among any of the sample types and the negative controls. Here, 16S ribosomal RNA gene sequencing of the maternal side of the placenta could not differentiate between bacteria in the placental tissue and contamination of the laboratory reagents with bacterial DNA. Probe-specific quantitative polymerase chain reaction for bacterial taxa suspected to be present in the placenta could not detect any statistically significant difference between the 2 groups. In bacterial cultures, substantially more bacteria were observed in the placenta layers from vaginal deliveries than those from cesarean deliveries. In addition, 16S ribosomal RNA gene sequencing of bacterial colonies revealed that most of the bacteria that grew on the plates were genera typically found in human skin; moreover, it revealed that placentas delivered vaginally contained a high prevalence of common vaginal bacteria. Bacterial growth inhibition experiments indicated that placental tissue may facilitate the inhibition of bacterial growth. CONCLUSION: We found no evidence to support the existence of a placental microbiome in our study of 76 term pregnancies, which used polymerase chain reaction amplification and sequencing techniques and bacterial culture experiments. Incidental findings of bacterial species could be due to contamination or to low-grade bacterial presence in some locations; such bacteria do not represent a placental microbiome per se.

Women's expectations and experiences of labor induction - a questionnaire-based analysis of a randomized controlled trial.

BACKGROUND: Although labor induction is a commonly used procedure in obstetrical care, there are limited data on its psycho-emotional effects on the woman. This study analysed the expectations and experiences of women in different routes of labor induction. The study's primary aim was to compare women's delivery experience if induced by orally administrated misoprostol (OMS) compared with misoprostol vaginal insert (MVI). Secondly, an evaluation of women's general satisfaction with induced labor was made, and factors associated with a negative experience. METHODS: Primiparous women (n = 196) with a singleton fetus in cephalic presentation, ≥ 37 weeks of gestation, with a Bishop's score ≤ 4 planning labor induction were randomly allocated to receive either OMS (Cytotec®) or MVI (Misodel®). Data were collected by validated questionnaires, the Wijma Delivery Expectation/Experience Questionnaire (A + B). The pre-labor part of the survey (W-DEQ version A) was given to participants to complete within 1 hour before the start of induction, and the post-labor part of the questionnaire (W-DEQ version B) was administered after birth and collected before the women were discharged from hospital. RESULTS: It was found that 11.8% (17/143) reported a severe fear of childbirth (W-DEQ A score ≥ 85). Before the induction, women with extreme fear had 3.7 times increased risk of experiencing labor induction negatively (OR 3.7 [95% CI, 1.04-13.41]). CONCLUSION: No difference was identified between OMS and MVI when delivery experience among women induced to labor was analysed. Severe fear of childbirth before labor was a risk factor for a negative experience of labor induction. TRIAL REGISTRATION: Clinical trial register number NCT02918110 . Date of registration on May 31, 2016.

Relationship between various maternal conditions and lactic acid dehydrogenase activity in umbilical cord blood at birth.

BACKGROUND: Lactic acid dehydrogenase (LDH) is a valuable marker for some of the most important diseases in newborns and the plasma LDH activity in newborns correlates well with conditions such as asphyxia. If LDH should be considered as a useful tool also in obstetric care, key factors associated with maternal health before and during pregnancy which could affect umbilical cord LDH activity need to be known. The aims of this study were to explore relationships between selected maternal conditions and arterial lactic acid dehydrogenase activity (aLDH) in umbilical cord blood at delivery. METHODS: A prospective observational study was conducted at Sodersjukhuset, Stockholm, Sweden. Included in the study were 1247 deliveries, and cord blood samples from each were analyzed for aLDH. Background, delivery and neonatal data were collected from the medical records. RESULTS: Higher median values of aLDH were found (P=0.001) among women with chronic disorders not related to pregnancy but there was no increased frequency of high aLDH levels (>612 µ/L, P=0.30). No difference in aLDH was identified between infants born to women with pregnancy-related disorders compared with healthy women, neither in median values, nor in high values (>612 µ/L, P=0.95). CONCLUSION: Newborn infants born to women with non-pregnancy-related chronic disorders had a somewhat higher median value of aLDH in cord blood at delivery. The influence of common maternal conditions and diseases on umbilical cord arterial LDH levels is small compared to the increase reported in fetal distress and several other critical conditions in the newborn.

Level of lactate in amniotic fluid and its relation to the use of oxytocin and adverse neonatal outcome.

OBJECTIVE: To assess whether the frequency of adverse neonatal outcome at delivery is related to the level of lactate in amniotic fluid and to the use of oxytocin. DESIGN: Prospective observational study. SETTING: Soder Hospital, Stockholm, Sweden. POPULATION: Seventy-four women in active labor with a gestational age ≥36 weeks and mixed parity. METHODS: Levels of lactate in amniotic fluid were analyzed bedside from an intrauterine catheter every 30 min during labor. Deliveries were divided into groups with and without oxytocin. MAIN OUTCOME MEASURES: The frequency of adverse neonatal outcome at delivery. RESULT: Of the deliveries 13.5% (10/74) concluded with an adverse neonatal outcome. The levels of lactate in amniotic fluid increased during labor, more so in deliveries where oxytocin was used. In the group with an adverse neonatal outcome, the level of lactate in amniotic fluid was significantly higher in the final sample before delivery (p = 0.04). In 18 deliveries, stimulation with oxytocin was temporarily halted for at least 30 min due to overly stimulated labor contractions. A decreasing level of lactate in amniotic fluid was shown within a median 5%/30 min. In the group where the administration of oxytocin was halted, there was no adverse neonatal outcome. CONCLUSION: The frequency of adverse neonatal outcome was associated with the level of lactate in amniotic fluid and with the use of oxytocin. The level of lactate in amniotic fluid may be an additional valuable tool when oxytocin is administered during labor.

The association between labour variables and primiparous women's experience of childbirth; a prospective cohort study.

BACKGROUND: Studies have suggested several risk factors for a negative birth experience among primiparas. Factors that are mentioned frequently include labour dystocia, operative intervention such as acute caesarean section or vacuum extraction, or the infant being transferred to neonatal care. Another important factor mentioned is lack of support from the midwife. METHODS: A study was made of the deliveries of 446 healthy primiparas in a prospective cohort study performed at Soder Hospital, Stockholm, Sweden. Samples of amniotic fluid were collected at delivery and the levels of amniotic fluid lactate (AFL) were measured to give an indication of the metabolism of the uterine tissue. Obstetrical data were collected from birth records.Postpartum, all the women included in the study were asked to complete the Wijma Delivery Experience Questionnaire (W-DEQ B) that measures the experience of a woman's delivery. The main objective of the project was to study well-known as well as new factors associated with negative experience of childbirth among a group of healthy primiparas. RESULTS: Risk factors for reporting a higher level of negative childbirth experience were shown to be a high level of AFL (AOR 3.1, 95%, CI; 1.1-8.9), a longer latent phase (AOR 1.8, 95%, CI; 1.03-3.1), and a low Apgar score (<7 at 1 min) (AOR 13.3, 95%, CI; 1.6-111.0). Those women who had a negative birth experience wanted the midwife to be present more of the time during labour (p = 0.003). CONCLUSIONS: A high AFL level, as a marker of uterine metabolic status, and a longer latent phase are strongly associated with a negative experience of childbirth. A low 1 minute Apgar score of the newborn seems to have the strongest negative influence on the woman's experience of childbirth, even when the infant recovers immediately.

Amniotic fluid lactate (AFL): a new predictor of labor outcome in dystocic deliveries.

PURPOSE OF THIS REVIEW: Even today, hundreds of thousands of women die or suffer high levels of morbidity associated with childbirth. One of the most common causes is halted labor progress, or labor dystocia. There have been no developments in the diagnosis or treatment of dystocic deliveries since Friedman designed the Partogram in the 1950s. Oxytocin is the only treatment for dystocic labor. Sometimes, oxytocin is a lifesaver for the woman, especially in severe postpartum hemorrhages. At the same time, it is also one of the most overused drugs in obstetric care. This review article is meant to provide a short overview of the current knowledge of uterine metabolism during labor, uterine lactate production, and its association with labor dystocia. The article also intends to reflect new ways of thinking regarding practical recommendations for treating labor dystocia and offer a look at the future of dystocic labor management.

Is there an increased risk of cesarean section in obese women after induction of labor? A retrospective cohort study.

BACKGROUND: Obesity is increasing in Sweden and is also of huge global concern. Obesity increases the risk of complications during pregnancy and the need for the induction of labor. Induction of labor increases the number of complications during delivery, leading to women with more negative birth experience. This study investigated how maternal body mass index (BMI) during antenatal care enrollment affects labor outcomes (proportion of cesarean section at induction of labor). METHOD: This was a retrospective cohort study of 3772 women with mixed parity and induction of labor at Soderhospital, Stockholm, in 2009-2010 and 2012-2013. The inclusion criteria were simplex, ≥34 gestational weeks, cephalic presentation and no previous cesarean section. The women were grouped according to BMI, and statistical analyzes were performed to compare the proportion of cesarean sections after induction of labor. The primary outcome was the proportion of cesarean section after induction of labor divided by group of maternal BMI. The secondary outcomes were postpartum hemorrhage >1000 ml, time of labor, fetal outcome data, and indication for emergency cesarean section. RESULT: The induction of labor in women with a high BMI resulted in a significantly increased risk of cesarean section, with 18.4-24.1% of deliveries, depending on the BMI group. This outcome persisted after adjustment in women with BMI 25-29.9 (aOR 1.4; 95% CI; 1.1-1.7) and BMI 30-34.9 (aOR 1.5; 95% CI; 1.1-2.1). There was also a significantly higher risk for CS among primiparous women (aOR 3.6; 95% CI; 2.9-45) and if the newborn weighted ≥ four kilos (aOR 1.6; 95% CI; 1.3-2.0). CONCLUSION: Our findings show that a higher BMI increased the risk of cesarean section after induction of labor in the groups with BMI 25-34.9. Parity seems to be the strongest risk factor for CS regardless other variables.

Body mass index and labor outcome associated with the level of amniotic fluid lactate. A cross-sectional study of women with labor dystocia.

INTRODUCTION: Obesity is a globally growing problem. Labor dystocia is associated with obstetric complications, especially among obese pregnant women. Previous studies have shown an association between the level of lactate produced by uterine myocytes during contractions and the level of lactate in the amniotic fluid (AFL). A relationship between a high level of AFL and labor dystocia has also been demonstrated. However, it is still unknown whether the observation applies to all women with labor dystocia, regardless of body mass index (BMI). Aims: This study investigated whether there was any difference in the level of AFL in the three BMI groups and whether there was a difference in labor outcomes between high and low AFL in the different groups. MATERIALS AND METHODS: This cross-sectional study included 1683 women from three different countries. Healthy nulliparous women in active labor were included, and they were grouped according to BMI as normal weighted (<25), overweight (≥25-29), and obese (≥30), respectively. AFL was categorized as high (≥10.1 mmol/l) and low (<10.1 mmol/l). The main outcome was the frequency of cesarean section. RESULTS: No difference in AFL levels was found between the three BMI groups at delivery (mean values of 8.2 vs. 8.3 vs. 8.4 mmol/l, p = .3). Obese women with high AFL had a higher frequency of cesarean section than normal-weighted women (16.2 vs. 20.7 vs. 29.2%). Other risk factors associated with cesarean section varied among the different BMI groups. CONCLUSIONS: This study showed no difference in the mean level of AFL between women with different BMIs. Further, high AFL was associated with a higher frequency of cesarean section in all three BMI groups, suggesting that the level of AFL can in the future be used as a predictor of labor outcome among women with labor dystocia despite their BMI.

Fetal scalp blood sampling during second stage of labor - analyzing lactate or pH? A secondary analysis of a randomized controlled trial.

BACKGROUND: Cardiotocography (CTG) is a widely used method for assessing fetal wellbeing during labor. It is well-known that CTG has high sensitivity but low specificity. To avoid unnecessary operative interventions, adjunctive methods such as fetal blood sampling (FBS) are used. Few studies have looked into whether FBS can be used during second stage of labor, and in that case, which of the methods (lactate or pH) are preferred. OBJECTIVE: To evaluate clinical effectiveness of measuring lactate versus pH in preventing birth acidemia when FBS was performed during second stage of labor. METHODS: Secondary analysis of a randomized controlled trial . Thousand three hundred and thirty-eight women with a singleton pregnancy, cephalic presentation, gestational age ≥34 weeks, and indication for FBS during second stage of labor were included. MAIN OUTCOME MEASURES: Metabolic acidemia (pH <7.05 and base deficit >12 mmol/l) or pH < 7.00 in cord arterial blood at birth. SECONDARY OUTCOMES: A composite outcome (metabolic acidemia, pH <7 or Apgar score <4), and rates of operative deliveries. RESULTS: Metabolic acidemia occurred in 4.1% in the lactate versus 5.1% in the pH group (relative risk (RR): 0.80; 95% confidence interval (CI): 0.48-1.35) and pH <7 in 1.4% versus 2.8% (RR: 0.51, 95% CI: 0.23-1.13). Composite outcome was found in 3.8 versus 4.9%, respectively (RR: 0.76; 95% CI: 0.46-1.26). No difference in total operative interventions was found. More cesarean deliveries were performed in the lactate group (16.5 vs. 12.4%; RR: 1.33; 95% CI: 1.02-1.74). CONCLUSION: When analyzing lactate or pH in fetal scalp blood during second stage of labor neonatal outcomes were comparable. The frequency of total operative interventions was similar but more cesarean deliveries were performed in the lactate group.

Predictive factors in pregnancies with reduced fetal movements: a pilot study.

BACKGROUND: Pregnancies with reduced fetal movements (RFM) are at risk for poor neonatal outcomes and stillbirth. AIM: To investigate whether Doppler measurements or angiogenic factors are good predictors of adverse neonatal outcomes in pregnancies with RFM. METHODS: This is a prospective pilot cohort study of 3243 women seeking care for RFM. Standard care was carried out in all cases. An extra Doppler examination was performed in 128 women to assess the flow in the middle cerebral artery, the umbilical artery, and the uterine artery. In 62/128 pregnancies, a maternal blood sample was obtained for angiogenic and antiangiogenic factors. The composite neonatal outcome of the study was one or more of the following factors: Apgar score <7 at 5', arterial aPh in the umbilical cord ≤7.1, transfer to Neonatal Intensive Care (NICU), stillbirth, and small for gestational age (SGA). RESULTS: In 14.1% (18/128) of the Doppler group and 11.7% (365/3115) of the standard care group, there was an adverse neonatal outcome (p = .51). A higher intervention rate was found in the Doppler group (28% vs. 5.4%, p < .01). The predictive model of adverse neonatal outcomes in women with RFM with angiogenic factors was 0.73 (95% CI 0.54-0.92). The area under the curve improved to 0.89 (CI 95% 0.81-0.97) when parity was added to the model. CONCLUSION: Angiogenic factors may have a place in the prediction of the neonatal outcome of RFM pregnancies. The prediction model's capacity was driven by parity. The obstetrical intervention rate increased with additional Doppler examinations.

Assessment of pain in women randomly allocated to speculum or digital insertion of the Foley catheter for induction of labor.

OBJECTIVE: The primary aim was to assess pain subjectively and objectively in women during insertion of a Foley catheter for induction of labor. A secondary aim was to assess pain during cervical ripening and to evaluate maternal satisfaction. DESIGN: Randomized controlled trial. SETTING: University hospital, Sweden. POPULATION: Forty-two women undergoing induction of labor and cervical ripening with a Foley catheter. METHODS: Women were randomly allocated to digital (n=21) or to speculum (n=21) placement of a Foley catheter. A visual analogue scale (VAS) was used for subjective assessment of pain and, for objective measurements, a skin conductance algesimeter was used and the area under the curve (AUC) was calculated (µSs). Maternal satisfaction was evaluated in a questionnaire. MAIN OUTCOME MEASURES: Pain sensation during placement of the Foley catheter. RESULTS: There was a significant difference between groups in pain measurements during insertion of the Foley catheter. The speculum group had higher median pain scores than the digital group, VAS=5 vs. = 3 (p=0.03) and greater median AUC measurements: 1840 vs. 823 µSs (p=0.04). There was no difference in pain assessments during cervical ripening. Overall satisfaction scores were high and comparable between groups. CONCLUSION: Digital placement of the Foley catheter is subjectively and objectively less painful compared to the use of a speculum. Digital placement should therefore be considered as an alternative in the management of these patients. Ripening of the cervix with the Foley catheter is well tolerated and the overall satisfaction rate among patients induced with this method is high.

Swedish guidelines for type 1 diabetes and pregnancy outcomes: A nationwide descriptive study of consensus and adherence.

AIMS: Type 1 diabetes (DM1) during pregnancy and labor is associated with an increased risk of maternal and fetal complications. Evidence-based care is therefore provided in accordance with guidelines. In this study, we aimed to compare all the Swedish guidelines for DM1 during pregnancy and labor in terms of the variables emphasized in the national guidelines from the US and from England and Wales. The second aim was to measure adherence to local guidelines at the four hospitals in Stockholm that cared for pregnant women with DM1 during 2016 and to describe the pregnancy and labor outcomes. METHODS: All the Swedish guidelines for DM1 during pregnancy and labor were reviewed on 31 variables. The medical records of 114 women were reviewed according to whether ≥70% of 22 variables in the guidelines were followed. RESULTS: No consensus was found in the Swedish guidelines for any of the 31 variables. Some guidelines were contradictory. The pregnancy guidelines were followed in 17.5% of the medical records, 18.4% followed the labor guidelines, and 5.3% followed both guidelines. The onset of labor, mode of delivery and HbA1c in the third trimester varied significantly, depending on the adherence to guidelines. CONCLUSIONS: The Swedish guidelines for DM1 during pregnancy and labor lack both consensus and adherence. A national guideline on DM1 during pregnancy and childbirth with high adherence could improve care for pregnant Swedish women with DM1 and their fetuses.

Lactate dehydrogenase predicts hypoxic ischaemic encephalopathy in newborn infants: a preliminary study.

BACKGROUND: Enzyme leakage as a result of hypoxia-ischaemia induced cell damage in affected organs is seen together with hypoxic ischaemic encephalopathy (HIE) after perinatal asphyxia. AIM: To investigate whether plasma lactate dehydrogenase [LDH], alanine aminotransferase [ALT] and aspartate aminotransferase [AST] during the first 12 h after birth predict HIE and adverse neurodevelopment outcome in newborn term infants with intra-partum signs of foetal distress. METHODS: Enzymes were measured within 12 h post partum in newborn infants with differing degree of HIE (n = 41) and in infants with signs of foetal distress during birth (n = 205) without HIE (non-HIE group). All infants were randomized into two groups. One group (n = 123) was used for calculation of cut off limits for the enzymes studied and the other group (n = 123) was used for calculation of the predictive value of the enzymes for detection of HIE. RESULTS: Using ROC curves, a cut off level of 1049 U/L for [LDH] was the best predictor of HIE (sensitivity 100% and specificity 97%) but also for long term outcome after HIE. CONCLUSION: [LDH] is a good predictor of HIE during the first 12 h after birth. This result is of clinical interest offering a potential inexpensive and safe prognostic marker in newborn infants with perinatal asphyxia.

Lactate distribution in culture medium of human myometrial biopsies incubated under different conditions.

It is generally believed that a relationship exists between muscle fatigue and intracellular accumulation of lactate. This reasoning is relevant to obstetrical issues. Myocytes in uterus work together during labor, and the contractions need to be strong and synchronized for a child to be delivered. At labor dystocia, the progress of labor becomes slow or arrested after a normal beginning. It has been described that, during labor dystocia, when the force of the contractions is low, the uterus is under hypoxia, and anaerobic conditions with high levels of lactate in amniotic fluid dominate. The purpose of this study was to examine whether myometrial cells are involved in the production of lactate in amniotic fluid and whether there are differences in production and distribution of lactate in cells incubated under aerobic and anaerobic conditions. We also wanted to elucidate the involvement of specific membrane-bound lactate carriers. Women undergoing elective caesarean section were included. Myometrial biopsies from uteri were collected and subjected to either immunohistochemistry to identify lactate carriers or in vitro experiments to analyze production of lactate. The presence of lactate carriers named monocarboxylate transporters 1 and 4 was verified. Myometrial cells produced lactate extracellularly, and the lactate carriers operated differently under anaerobic and aerobic conditions; while being mainly unidirectional under anaerobic conditions, they became bidirectional under aerobic conditions. Human myometrial cells produced and delivered lactate to the extracellular medium under both anaerobic and aerobic conditions. The delivery was mediated by lactate carriers.

The association of second trimester biomarkers in amniotic fluid and fetal outcome.

Objective: To identify the level of amniotic fluid lactate (AFL), placental growth factor (PLGF), and vascular endothelial growth factor (VEGF) at second trimester amniocentesis, and to compare levels in normal pregnancies with pregnancies ending in a miscarriage, an intrauterine growth restricted fetus (IUGR) or decreased fetal movements. Study design: A prospective cohort study. Amniotic fluid was consecutively collected at amniocentesis in 106 pregnancies. Fetal wellbeing at delivery was evaluated from medical files and compared with the levels of AFL, VEGF, and PLGF at the time of amniocentesis. Results: The median level of AFL was 6.9 mmol/l, VEGF 0.088 pg/ml, and PLGF 0.208 pg/ml. The median levels of AFL in pregnancies ended in miscarriage were significantly higher (10.7 mmol/l) compared to those with a live new-born (6.9 mmol/L, p = .02). The levels of VEGF (p = .2) and PLGF (p = .7) were not affected. In pregnancies with an IUGR, the median level of AFL was higher compared to those with normal fetal growth (p = .003). No differences VEGF (p = .5), but significant lower PLGF were found in IUGR pregnancies (p = .03). Conclusions: Pregnancies ending in a miscarriage or with IUGR had significantly higher median values of AFL but lower values of PLGF in the amniotic fluid at the time of second trimester amniocentesis compared to normal pregnancies.

High-dose versus low-dose of oxytocin for labour augmentation: a randomised controlled trial.

PROBLEM: Delayed labour progress is common in nulliparous women, often leading to caesarean section despite augmentation of labour with synthetic oxytocin. BACKGROUND: High- or low-dose oxytocin can be used for augmentation of delayed labour, but evidence for promoting high-dose is weak. Aim To ascertain the effect on caesarean section rate of high-dose versus low-dose oxytocin for augmentation of delayed labour in nulliparous women. Methods Multicentre parallel double-blind randomised controlled trial (ClinicalTrials.gov: NCT01587625) in six labour wards in Sweden. Healthy nulliparous women at term with singleton cephalic fetal presentation, spontaneous labour onset, confirmed delay in labour and ruptured membranes (n=1351) were randomised to labour augmentation with either high-dose (6.6 mU/minute) or low-dose (3.3 mU/minute) oxytocin infusion. FINDINGS: 1295 women were included in intention-to-treat analysis (high-dose n=647; low-dose n=648). Caesarean section rates did not differ between groups (12.4% and 12.3%, 95% Confidence Interval -3.7 to 3.8). Women with high-dose oxytocin had: shorter labours (-23.4min); more uterine tachysystole (43.2% versus 33.5%); similar rates of instrumental vaginal births, with more due to fetal distress (43.8% versus 22.7%) and fewer due to failure to progress (39.6% versus 58.8%). There were no differences in neonatal outcomes. DISCUSSION: Our study could not confirm results of two systematic reviews indicating, with weak evidence, that use of high-dose oxytocin was associated with lower frequency of caesarean section. CONCLUSION: We found no advantages for routine use of high-dose oxytocin in the management of delay in labour. Low-dose oxytocin regimen is recommended to avoid unnecessary events of tachysystole and fetal distress.

Association between lactate concentration in amniotic fluid and dysfunctional labor.

OBJECTIVES: To assess whether there is an association between high lactate concentration in amniotic fluid (AF) and labor dystocia. DESIGN: Prospective observational study. SETTING: Labor ward at General South Hospital, Stockholm, Sweden. POPULATION AND METHODS: Women in active labor attending labor ward, having at least two consecutive measurements of lactate concentration in AF, measured 60 minutes apart. MAIN OUTCOME MEASURE: Dysfunctional labor, defined as instrumental or operative delivery due to dystocia. RESULTS: Among women with spontaneous vaginal deliveries (n=23) the mean lactate concentration in AF during labor was 8.9 mmol/l (range 6.6-10.8), and among women with operative delivery due to labor dystocia (n=31) the corresponding value was 10.9 mmol/l (range 8.0-16.1) (p<0.001). Of 29 women with a high lactate concentration (> or =10.1 mmol/l) in at least two consecutive measures collected at least 60 minutes apart, 25 (86%) were delivered instrumentally/operatively due to dystocia. Using this definition of a positive test, the diagnostic accuracy to predict operative delivery due to dystocia was: sensitivity 81% (25/31), specificity 83% (19/23), positive predictive value 86% (25/29), and negative predictive value 76% (19/25). The likelihood ratio was 5.0 for a positive test and 0.2 for a negative test. CONCLUSIONS: High lactate concentration (> or =10.1mmol/l) in at least two consecutive samples of AF collected during labor 60 minutes apart is strongly associated with dystocia. This method might be useful in clinical management to identify labor dystocia at an early stage of labor.

A randomized controlled trial of a new treatment for labor dystocia.

OBJECTIVE: Labor dystocia is an intransigent, high-profile issue in obstetric care. Amniotic fluid lactate (AFL) reflects the uterine metabolic status. High levels associate with subsequent need for operative intervention due to dystocia. In sports medicine, it is known that lactic acid can affect muscular performance and can be decreased by bicarbonate given orally before physical activity. MATERIAL AND METHODS: Two hundred dystocic deliveries were included. At the confirmation of dystocia, the AFL-level was analyzed. Deliveries were randomized to an intake of bicarbonate or not. In the "non-bicarbonate-group", stimulation with oxytocin was started immediately. In the "bicarbonate-group", bicarbonate was given; and oxytocin was started 1 hour after the intake. New sampling of AF was performed after 1 hour in both groups. OUTCOME MEASURED: if an oral intake of bicarbonate changes the AFL levels and enhances delivery outcome in dystocic deliveries. RESULTS: Bicarbonate decreases the AFL levels (p < .001). The spontaneous vaginal delivery rate after treatment with bicarbonate was increased (p = .007), without affecting the fetal outcome. CONCLUSIONS: An increase of spontaneous vaginal deliveries resulted from bicarbonate ingestion by dystocic women. A decreased level of AFL-level was shown. This simple, low cost treatment has the potential to improve maternal morbidity and satisfaction worldwide.