Blood pressure levels but not hypertensive complications have increased in Type 1 diabetes pregnancies during 1989-2010.

AIMS: The pre-pregnancy BMI and the third trimester HbA(1c) levels increased in Finnish parturients with Type 1 diabetes during 1989-2008. The aim of the present study was to investigate whether these trends have been accompanied by increases in blood pressure or hypertensive complications. Hypertension trends were analysed using the definitions of hypertension of both the American College of Obstetricians and Gynecologists and the American Diabetes Association. The associations of hypertension, as defined by the latter criteria, with perinatal complications were also studied. METHODS: The records of a cohort of 1007 consecutive patients with Type 1 diabetes with a singleton live childbirth during 1989-2010 at the Helsinki University Central Hospital were studied. RESULTS: The frequencies of hypertensive pregnancy complications did not change, but the mean diastolic blood pressure increased in normotensive parturients in all trimesters. The proportion of patients with systolic blood pressure > 130 mmHg or diastolic blood pressure > 80 mmHg in the first, second and third trimesters of pregnancy increased from 25 to 33%, from 26 to 35% and from 57 to 71%, respectively. Systolic blood pressure of 131-139 mmHg or diastolic blood pressure of 81-89 mmHg in the third trimester was associated with umbilical artery pH < 7.15. CONCLUSIONS: Blood pressure of patients with Type 1 diabetes during pregnancy is increasing. A growing proportion of women with Type 1 diabetes exceed the American Diabetes Association's definition of hypertension during pregnancy.

Trends in maternal BMI, glycaemic control and perinatal outcome among type 1 diabetic pregnant women in 1989-2008.

AIMS/HYPOTHESIS: Our objective was to examine the trends in prepregnancy BMI and glycaemic control among Finnish type 1 diabetic patients and their relation to delivery mode and perinatal outcome. METHODS: We analysed the obstetric records of 881 type 1 diabetic women with a singleton childbirth during 1989-2008. Maternal prepregnancy weight and height were obtained from the maternity cards, where they are recorded as reported by the mother. RESULTS: Maternal BMI increased significantly during 1989-2008 (p < 0.001). The mean HbA(1c) in the first trimester remained unchanged, but the midpregnancy and the last HbA(1c) before delivery increased (p = 0.009 and 0.005, respectively). Elective Caesarean sections (CS) decreased (p for trend <0.001), while emergency CS increased (p for trend <0.001). The mean umbilical artery (UA) pH decreased in vaginal deliveries (p for trend <0.001). The frequency of UA pH <7.15 and <7.05 increased (p for trend <0.001 and 0.008, respectively). The macrosomia rate remained at 32-40%. Neonatal intensive care unit (NICU) admissions increased (p for trend 0.03) and neonatal hypoglycaemia frequency decreased (p for trend 0.001). In multiple logistic regression analysis, maternal BMI was associated with macrosomia and NICU admission. The last HbA(1c) value before delivery was associated with delivery before 37 weeks' gestation, UA pH <7.15, 1 min Apgar score <7, macrosomia, NICU admission and neonatal hypoglycaemia. CONCLUSIONS/INTERPRETATION: Self-reported pregestational BMI has increased and glycaemic control during the second half of pregnancy has deteriorated. Poor glycaemic control seems to be associated with the observed increases in adverse obstetric and perinatal outcomes.

Elevated levels of decidual insulin-like growth factor binding protein-1 in cervical fluid in early and mid-pregnancy are associated with an increased risk of spontaneous preterm delivery.

OBJECTIVE: To study whether elevated levels of decidual insulin-like growth factor binding protein-1 (IGFBP-1) in the cervical fluid of unselected asymptomatic women in early or mid-pregnancy are associated with spontaneous preterm delivery (PTD). DESIGN: Prospective population-based cohort study. SETTING: Maternity Clinics, University Central Hospital, Helsinki, Finland. POPULATION: A total of 5180 unselected pregnant women. METHODS: Cervical swab samples were collected during the first and second trimester ultrasound screening. The concentration of IGFBP-1 was measured by immunoenzymometric assay, which detects the decidual phosphoisoforms of IGFBP-1 (phIGFBP-1). Concentrations of 10 micrograms/l or more were considered to be elevated. MAIN OUTCOME MEASURE: Spontaneous PTD. Results In the first trimester, 24.5% of women, and in the mid-second trimester, 20.2% of women, had an elevated cervical fluid phIGFBP-1 level. The rates of spontaneous PTD before 32 and before 37 weeks of gestation were higher in women with an elevated cervical fluid phIGFBP-1 level, compared with women who had cervical phIGFBP-1 of <10 micrograms/l (1.1% versus 0.3% and 5.7% versus 3.2%, respectively). An elevated phIGFBP-1 level in the first trimester was an independent predictor for PTD before 32 and before 37 weeks of gestation, with odds ratios of 3.0 (95% CI 1.3-7.0) and 1.6 (95% CI 1.2-2.3), respectively. Cervical phIGFBP-1 levels of 10 micrograms/l or more in the first trimester predicted PTD before 32 and before 37 weeks of gestation, with sensitivities of 53.8% and 37.0%, respectively. The negative predictive values were 99.7% and 96.8%. CONCLUSIONS: Elevated cervical fluid phIGFBP-1 levels in the first trimester were associated with an increased risk of spontaneous PTD.

Prediction of placental abruption by testing for C-reactive protein and chlamydial antibody levels in early pregnancy.

OBJECTIVE: Placental abruption may be a manifestation of acute and chronic inflammatory process. We wanted to assess the association of first-trimester serum C-reactive protein (CRP), Chlamydia pneumoniae antibodies, Chlamydia trachomatis antibodies or chlamydial heat-shock protein 60 (CHSP60) antibodies to placental abruption. DESIGN: Retrospective case-control study. SETTING: University Hospital. POPULATION: A total of 181 women with subsequent placental abruption and 261 control women with normal pregnancy. METHODS: Serum samples collected at first trimester (mean 10.4 gestational weeks) were analysed for CRP levels, C. pneumoniae-specific immunoglobulin G (IgG) and immunoglobulin A (IgA) antibodies and C. trachomatis-specific IgG, IgA and CHSP60 antibodies. MAIN OUTCOME MEASURE: Placental abruption. RESULTS: The levels of CRP showed no difference between the cases and the controls (median 2.35 mg/l [interquartile range {IQR} 1.09-5.93] versus 2.28 mg/l [IQR 0.92-5.01], not significant). C. pneumoniae-specific IgG and IgA as well as C. trachomatis-specific IgG, IgA and CHSP60 antibody frequencies were similar between the groups. There was no association between CRP levels and chlamydial antibodies. CONCLUSION: These markers of inflammation in early pregnancy failed to predict subsequent placental abruption.

Diurnal blood pressure variations and onset of subarachnoid haemorrhage: a population-based study.

OBJECTIVES: To analyse the association between time of onset of subarachnoid haemorrhage and diurnal blood pressure variations of ambulant normo- and hypertensive subjects. DESIGN: Retrospective, population-based study. SETTING: The population (246,000) of the Health Care District of Central Finland. PATIENTS: During 1980-1987 a total of 332 subjects in the study population had their first subarachnoid haemorrhage. The hour of onset could be obtained for 287 patients, and these form the basis of the present study. RESULTS: The onset of subarachnoid haemorrhage occurred significantly more often during the waking hours than during the night. The correlation between the hourly numbers of patients suffering a haemorrhage and the corresponding mean systolic and diastolic blood pressure values of ambulant normo- and hypertensive subjects was highly significant (r = 0.88, P < 0.001). The results were similar when the 224 patients with proved aneurysmal bleed were analysed separately (r = 0.79-0.85, P < 0.001). CONCLUSIONS: The diurnal blood pressure variations of ambulant normo- and hypertensive subjects, especially the transient blood pressure peaks reaching much higher levels of pressure during the waking hours than during the night, may be crucial in determining the time of rupture of a critically weakened aneurysm wall.

A comparison between two doses of intravaginal misoprostol and gemeprost for induction of second-trimester abortion.

OBJECTIVE: To compare the abortifacient efficacies of two intravaginally administered misoprostol doses and gemeprost in termination of second-trimester pregnancy. METHODS: Eighty-one women between 12 and 24 weeks' gestation requesting abortion were randomized to receive intravaginally either 100 micrograms of misoprostol at 6-hour intervals (n = 27), 200 micrograms of misoprostol at 12-hour intervals (n = 26), or 1.0 mg of gemeprost at 3-hour intervals (n = 28). The regimen was continued until abortion, or for 36 hours, with assessment of the rate of complete and incomplete abortions as well as side effects within 48 hours from the start of the treatment. RESULTS: The final rates of terminations were 74% in the 100-microgram misoprostol group, 92% in the 200-microgram misoprostol group, and 89% in the gemeprost group. Abortion was complete in 37%, 61%, and 32% in each group, respectively (P = .03, when the 200-microgram misoprostol group was compared with the two other groups). The induction-to-abortion interval was longer (P = .001) in the misoprostol groups (mean 23.1 hours for the 100-microgram and 27.8 hours for the 200-microgram dose) than in the gemeprost group (14.5 hours). There was less pain (P = .01), diarrhea (P = .001), and vomiting (P = .01) in the misoprostol groups than in the gemeprost group. The mean blood loss in the misoprostol groups was lower than in the gemeprost group (P = .001). CONCLUSION: Intravaginal application of 200 micrograms of misoprostol at 12-hour intervals in induction of second-trimester abortion is equally effective to a standard gemeprost regimen. Misoprostol causes fewer side effects and is cheaper and more practical to use.

Phosphorylated isoforms of insulin-like growth factor binding protein-1 in the cervix as a predictor of cervical ripeness.

OBJECTIVE: To study the isoforms of insulin-like growth factor binding protein-1 (IGFBP-1) in cervical secretion and to evaluate whether their assessment could serve in prediction of cervical ripeness at term. METHODS: We measured the concentrations of IGFBP-1 in cervical swab samples of 64 women scheduled for labor induction by amniotomy or cervical ripening with prostaglandin E2 gel. Two immunoenzymometric assays were used: a previously described assay 1, which detects the nonphosphorylated and lesser phosphorylated isoforms, and a novel assay 2, which detects the lesser and highly phosphorylated isoforms of IGFBP-1. A set of 39 amniotic fluid (AF) samples also was analyzed to compare the phosphorylation status of IGFBP-1 in cervical secretion with that in AF. RESULTS: In all cervical samples, IGFBP-1 concentration was higher by assay 2 than by assay 1, whereas in all AF samples, the results were the opposite. Initially, the median IGFBP-1 concentration in the ripe cervices (Bishop scores 6 or greater; n = 29) was approximately four times as high as that in the unripe cervices (Bishop scores 5 or less; n = 35). The cervical IGFBP-1 concentrations increased eight-fold in 6 hours after the first application of PGE2. CONCLUSION: Phosphorylated isoforms of IGFBP-1, different from those in AF, are present in the cervical secretion of women with intact fetal membranes and reflect cervical ripeness. A bedside test for those IGFBP-1 isoforms might help in predicting amenability for labor induction.

Local administration of prostaglandin E2 for cervical ripening and labor induction: the appropriate route and dose.

BACKGROUND: Although there are many comparative studies concerning the local administration of prostaglandin E2 gel for cervical ripening and labor induction, the safety, efficacy and the appropriate route and dose of the gel are still debated. PATIENTS AND METHODS: One hundred and ten women with high-risk pregnancy and unripe cervix received prostaglandin E2 gel 1 mg intravaginally (n=35), 2 mg intravaginally (n=36) and 0.5 mg intracervically (n=39), maximally three times at 6-hour intervals for cervical ripening prior to labor induction. The safety, efficacy and optimal dose were assessed. RESULTS: The 2 mg intravaginal gel and the 0.5 mg intracervical gel were equally effective and more effective than the 1 mg intravaginal gel in labor characteristics such as ripening time and cesarean section rate, but not in labor time. However, the failure rate (labor could not be induced) was highest in the intracervical group (10.3%) compared to the intravaginal groups (2.9% and 2.8%), although the differences were not statistically significant. In the two intravaginal groups three and five patients received the third gel application and one patient in both groups could not be induced. In the intracervical group the ripening of the cervix failed in all patients, who received the third gel. The neonatal outcome was uneventful in all groups. There were two cases of uterine hypertonus associated with fetal bradycardia, one in the intracervical and one in the 2 mg intravaginal group. Thus careful fetal monitoring is necessary. Furthermore, the vaginal route has the advantage of an easier technique of administration and obviously lower risk for inadvertent extraamnial instillation. CONCLUSION: We recommend the use of multiple applications of 2 mg intravaginal prostaglandin E2 gel as a safe, effective and easy method for preinduction cervical ripening in high-risk pregnancies. More than three gel applications hardly increase the efficacy.

Twin pregnancy with a fetus in each half of a uterus didelphys.

A rare case of a twin pregnancy with a fetus in each half of a uterus didelphys (double uterus, double cervix and septate vagina) is reported. A longitudinal vaginal septum and two portios were detected during the first labor of this patient. During her second pregnancy ultrasonography was performed in the 16th week, and pregnancy was detected in each half of the double uterus. Both fetuses were of similar size and corresponded to the gestational age. A completely separated double uterus was confirmed by ultrasonography. In the 38th week a female and a male infant were delivered by cesarean section. The follow-up of this pregnancy and the management of the labor are reported.

The cusp of Carabelli. Occurrence in first upper molars and evaluation of its heritability.

In a Finnish rural population 79.0% of 233 persons had the cusp of Carabelli in first upper molars. Of these 20% showed "positive cusps" and 59% "negative cusps". The occurrence of the structure was bilateral with varying degrees of asymmetry, but if there was no structure on one side of the jaw, the other never showed the cusp. There was no sexual dimorphism either in the occurrence or in the degree of expression of character. Results of the statistical analyses suggested low heritability of the character. However, the dichotomy of having a cusp or not may have genetic basis, but there is large variation in the expression of the "cusp-genotype".

Primary intracerebral haemorrhage in the Jyväskylä region, central Finland, 1985-89: incidence, case fatality rate, and functional outcome.

The age and sex specific incidence rates, the case fatality rates, and the functional outcome of patients with primary intracerebral haemorrhage occurring in a population of 116,000 during a period of four years four months are presented. A total of 158 patients were identified, the diagnosis was confirmed in 78% by CT, and in 22% by necropsy. The crude annual incidence rate was 31/100,000 population, the age specific rates increased from two to 222/100,000 from the age of 30-39 to over 80 years. Men had higher incidence rates between the ages of 40 and 79 years. The short term case fatality rate was high, 27% of patients dying during the first day after onset of symptoms, and 50% were dead at 30 days. After the first month the probability of survival did not differ from an age- and sex-matched average population. Large haematoma volume had an adverse effect on the short term, old age (greater than 70 years) on the long term survival. Ventricular extension, especially when combined with hydrocephalus was a bad omen for short term survival. Infratentorial and large basal ganglionic haematomas, and primary intraventricular haemorrhage carried a worse prognosis than haematomas of other locations. At the end of a median 32 month follow up 55 (35%) of the patients were alive, 51% of these were independent in activities of daily living, 45% were dependent on outside help, and 4% needed constant nursing care. Old age (greater than 70 years), but not the haematoma volume or location, was associated with a poor functional recovery.

Women's anticipations of and experiences with induction of labor.

BACKGROUND: Although induction of labor is a common procedure, there are limited data on its psychoemotional effects. We studied women's expectations of and experiences with labor induction in a large university hospital. PATIENTS AND METHODS: A total of 296 parturients were recruited, with 270 (91%) taken into the final analysis. Of these, 135 underwent elective induction of labor (44 with amniotomy and 91 with cervical ripening by the use of vaginal prostaglandin gel, followed by amniotomy), whereas the remaining 135 women gave birth spontaneously and served as controls. Each woman was interviewed as to her knowledge, expectations, and feelings about labor before induction or at start of labor (controls) as well as after delivery with the help of questionnaires containing yes/no or multiple-choice questions and visual analog scales. RESULTS: The induction and control groups, in regard to baseline clinical characteristics, did not differ. Labor ended in cesarean section for 24 women in the induction group (18%) and for 12 women in the control group (9%) (p=0.04); these women were included in the data analysis. In the induction group, 67%, and in the control group, 48% of women (p=0.002) reported having received sufficient information on labor induction from medical personnel at prenatal or obstetric clinics. Attitudes towards induction of labor were antenatally positive in 78% of women in the induction group and in 69% in the control group. The induction group reported fear of pain less often (45%) than the control group (57%) (p=0.03). In the induction group, 76 women (56%), and in the control group 94 women (70%) (p=0.02), wanted to participate in the decision on the method of induction, and 74% and 83%, respectively, wished to influence the timing of induction. When interviewed post partum, the labor experience corresponded with the patients' expectations better in the control than in the induction group (p=0.03). Labor induction was a positive experience in 90% of women who underwent immediate amniotomy and in 69% of those who received prostaglandin ripening first. CONCLUSION: Labor induction was a positive experience only seldom eliciting negative feelings. A third of the parturients undergoing induction need more information on the procedure and most want to participate in decision-making concerning the method and timing of induction.