Comprehensive evaluation of the incidence and prevalence of surgically diagnosed pelvic endometriosis in a complete population.

INTRODUCTION: The incidence and prevalence of pelvic endometriosis is still being debated. Population-based studies have shown annual incidences between 0.1% and 0.3%, which translates to a prevalence of symptom-giving disease of between 2% and 6% over a 20-year span in the reproductive years. However, a prevalence of 10% or higher is often assumed. We used Iceland's extensive record linkage possibilities, secure access to patient data and personal identification numbers to search for all cases with a surgical and/or histological first diagnosis over a 15-year study period. MATERIAL AND METHODS: Information was obtained from all healthcare facilities where an operative and/or histological diagnosis of pelvic endometriosis might have been made during 2001-2015. Hospital discharge diagnostic data and private clinic data sources were scrutinized and double-checked through a central register. Individual medical records, operation notes and pathology records were inspected. Visually and pathologically diagnosed cases were included. The data covered women aged 15-69 years, but the age range 15-49 (reproductive years) was specifically considered. Annual incidence was estimated per 10 000 person-years and prevalence possibilities calculated for varying disease durations. Disease severity was staged (revised American Society for Reproductive Medicine classification) and main lesion sites determined. RESULTS: A total of 1634 women 15-69 years old were diagnosed; 1487 of them between 15 and 49 years old. Histological verification was obtained for 57.1%. The age-standardized annual incidence for all confirmed endometriosis diagnoses was 12.5/10 000 person-years among women in their reproductive years. The overall estimate of prevalence was 0.6%-3.6%, dependent on duration of symptoms from 5 up to 30 years. The most common sites by order of frequency were ovaries, deep pelvis, central pelvis, vesicouterine pouch and uterine appendages. Of the women, 1080 (66.1%) had minimal/mild and 553 (33.8%) moderate/severe disease. CONCLUSIONS: We have in a comprehensive study covering a recent 15-year period confirmed an annual incidence of pelvic endometriosis of between 0.1% and 0.15% in the female population of reproductive age. Endometriosis is variably severe but, depending on the duration of symptomatic disease, the approximated prevalence during women's reproductive years could range from 1% to 4%.

[Maternal death in Iceland 1976-2015].

INTRODUCTION: Maternal deaths are rare and an indirect measure of the societal framework surrounding pregnancy and childbirth. We surveyed and classified maternal mortality in Iceland using international guidelines, calculating changes over a 40-year period. MATERIAL AND METHODS: Information from Statistics Iceland on women aged 15-49 years who died in 1985-2015 were cross-checked against birth registration and hospital admission data to identify women who died in pregnancy or ≤42 and within 43-365 days from birth or termination of a pregnancy. Data for 1976-1984 were searched manually. Case records and autopsy reports were scrutinized. Deaths were classified as direct, indirect or coincidental and as early or late. RESULTS: Among 1600 women 48 died in pregnancy or within a year after pregnancy. Births totaled 172369 and overall maternal mortality was 27.8/100.000 births. Maternal mortality by World Health Organization criteria (direct/indirect ≤42 days) occurred in 14 instances giving a maternal mortality ratio (MMR) of 8.1/100.000. Rates lowered between the first and last 10-year periods, particularly initially followed by a lesser downward trend. Direct deaths were 6, indirect 20, coincidental 22 (accidents, diseases). Causes of direct deaths were severe preeclampsia, pulmonary embolism and choriocarcinoma. Underlying causes of indirect deaths included cancer, diabetes, brain/heart conditions and suicide. No deaths occurred from ectopic pregnancy, hemorrhage or anesthesia. CONCLUSIONS: Maternal mortality in Iceland is among the lowest reported. Women died because of the pregnancy, from worsening of underlying conditions or coincidentally. Risk groups require better support. Continued attention to adverse health connected to maternity is essential.

Does metabolomic profile differ with regard to birth weight?

BACKGROUND: Macrosomia and child obesity are growing health-care issues worldwide. The purpose of the study was to evaluate how extremely high or low birth weight affects metabolic markers evaluated in newborn screening. METHODS: The study was register-based and included full-term singletons born in Iceland from 2009 to 2012 with newborn screening samples taken 72-96 h after birth. Three groups based on birth weight were compared: low birth weight (<2500 g), appropriate-for-gestational age, and extreme macrosomia (≥5000 g). The comparison was adjusted for possible confounding factors. RESULTS: Compared to appropriate-for-gestational age neonates, both low birth weight and extreme macrosomia were associated with higher levels of glutamic acid. The amino acids alanine and threonine were increased in low birth weight neonates. Free carnitine and some medium- and long-chain acylcarnitines were higher in low birth weight infants. Hydroxybutyrylcarnitine was lower in low birth weight infants, but higher in extremely macrosomic neonates. Acetylcarnitine was higher in low birth weight and extremely macrosomic neonates. Succinylcarnitine was lower and hexadecenoylcarnitine higher in macrosomic newborns. CONCLUSION: Low birth weight and extremely macrosomic neonates show distinctive differences in their metabolomic profile compared to appropriate-for-gestational age newborns. The differences are not explained by gestational age. IMPACT: The key message of this article is that both low birth weight and extremely macrosomic newborns show dissimilar metabolomic profiles compared to appropriate-for-gestational age neonates. The article contributes to knowledge on what affects evaluation of results in newborn screening. The impact of this article is to provide information on metabolism at both ends of the birth weight range after accounting for confounding factors including gestational age.

Mode of delivery was associated with transient changes in the metabolomic profile of neonates.

AIMS: To estimate potential differences in neonatal metabolomic profiles at birth and at the time of newborn screening by delivery mode. METHODS: A prospective study at Women's Clinic at Landspitali-The National University Hospital of Iceland. Women having normal vaginal birth or elective caesarean section from November 2013 to April 2014 were offered participation. Blood samples from mothers before birth and umbilical cord at birth were collected and amino acids and acylcarnitines measured by tandem mass spectrometry. Results from the Newborn screening programme in Iceland were collected. Amino acids and acylcarnitines from different samples were compared by delivery mode. RESULTS: Eighty three normal vaginal births and 32 elective caesarean sections were included. Mean differences at birth were higher for numerous amino acids, and some acylcarnitines in neonates born vaginally compared to elective caesarean section. Maternal blood samples and newborn screening results showed small differences that lost significance after correction for multiple testing. Many amino acids and some acylcarnitines were numerically higher in cord blood compared to maternal. Many amino acids and most acylcarnitines were numerically higher in newborn screening results compared to cord blood. CONCLUSION: We observed transient yet distinct differences in metabolomic profiles between neonates by delivery mode.

[Catamenial pneumothorax due to pulmonary endometriosis].

Endometriosis is a chronic condition causing menstrual pain, irregular bleeding and infertility among women. Although usually in the pelvis, it can manifest in atypical places. We describe a 39-year old woman with a previous endometriosis diagnosis who presented three times on the second menstrual day with dyspnea and chest pain. Imaging showed right-sided pneumothorax on all three occasions. Thoraco-scopy revealed endometriosis-like lesions. Histology was suggestive of endometriosis. After treatment with chemical pleurodesis and hormonal suppression she has remained symptom-free. Diagnosis should be obtained by concomitant thoraco- and laparoscopy with biopsies to verify the disease and give a basis for appropriate treatment.

Do female elite athletes experience more complicated childbirth than non-athletes? A case-control study.

OBJECTIVE: Previous studies have suggested that female athletes might be at higher risk of experiencing complications such as caesarean sections and perineal tears during labour than non-athletes. Our aim was to study delivery outcomes, including emergency caesarean section rates, length of the first and second stages of labour and severe perineal tears, in first-time pregnant elite athletes compared with non-athletes. METHODS: This is a retrospective case-control study comparing birth outcomes of primiparous female elite athletes engaging in high-impact and low-impact sports compared with non-athletic controls. The athletes had prior to birth competed at a national team level or equivalent. Participant characteristics and frequency of training for at least 3 years before a first pregnancy were collected via a self-administered questionnaire. Information on delivery outcome was retrieved from the Icelandic Medical Birth Registry. RESULTS: In total, 248 participated, 118 controls, 41 low-impact and 89 high-impact elite athletes. No significant differences were found between the groups with regard to incidence of emergency caesarean section or length of the first and second stages of labour. The incidence of third-degree to fourth-degree perineal tears was significantly higher (23.7%) among low-impact athletes than in the high-impact group (5.1%, p=0.01), but no significant differences were seen when the athletes were compared with the controls (12%; p=0.09 for low-impact and p=0.12 for high-impact athletes). CONCLUSION: Participation in competitive sports at the elite level was not related to adverse delivery outcome, including length of labour, the need for caesarean section during delivery and severe perineal tears.

Trends over 50 years with liberal abortion laws in the Nordic countries.

BACKGROUND: During the 1970s the Nordic countries liberalized their abortion laws. OBJECTIVE: We assessed epidemiological trends for induced abortion on all Nordic countries, considered legal similarities and diversities, effects of new medical innovations and changes in practical and legal provisions during the subsequent years. METHODS: New legislation strengthened surveillance of induced abortion in all countries and mandated hospitals that performed abortions to report to national abortion registers. Published data from the Nordic abortion registers were considered and new comparative analyses done. The data cover complete national populations. RESULTS AND CONCLUSIONS: After an increase in abortion rates during the first years following liberalization, the general abortion rates stabilized and even decreased in all Nordic countries, especially for women under 25 years. From the mid-1980s higher awareness about pregnancy termination led women to present at an earlier gestational age, which was accelerated by the introduction of medical abortion some years later. Most terminations (80-86%) are now done before the 9th gestational week in all countries, primarily by medical rather than surgical means. Introduction of routine ultrasound screening in pregnancy during the late 1980s, increased the number of 2nd trimester abortions on fetal anomaly indications without an overall increase in the proportion of 2nd relative to 1st trimester abortions. Further refinement of ultrasound screening and non-invasive prenatal diagnostic methods led to a slight increase in the proportion of early 2nd trimester abortions after the year 2000. Country-specific differences in abortion rates have remained stable over the 50 years of liberalized abortion laws.

Hormonal contraception and venous thromboembolism.

BACKGROUND: New studies about the influence of hormonal contraception on the risk of venous thromboembolism (VTE) have been published. AIM: To evaluate new epidemiological data and to propose clinical consequences. DESIGN: A literature survey. METHODS: Studies assessing the risk of specific types of hormonal contraception were evaluated, compared and set into a clinical perspective. RESULTS: The majority of newer studies have demonstrated a threefold increased risk of VTE in current users of medium- and low-dose combined oral contraceptives (COCs) with norethisterone, levonorgestrel (LNG) or norgestimate compared with non-users. The same studies have demonstrated a sixfold increased risk of VTE in users of combined pills with desogestrel, gestodene, drospirenone or cyproteroneacetate, and in users of the contraceptive vaginal ring, compared with non-users. The rate ratio of VTE between users of COCs with newer progestogens compared with users of COCs with LNG was 1.5-2.8 in seven studies and 1.0 in two studies. Progestogen-only contraception did not confer an increased risk of VTE in any study. The incidence rate of VTE in non-pregnant women aged 15-49 years using non-hormonal contraception is three per 10 000 years. CONCLUSIONS: For women starting on hormonal contraception, we recommend medium- or low-dose combined pills with norethisterone, LNG or norgestimate as first-choice preparations. For the many women who are users of COCs with newer progestogens, although the absolute risk of VTE is low, a change to combined pills with norethisterone, LNG or norgestimate may halve their risk of VTE. Finally, we recommend COCs with 20 µg estrogen combined with the older progestogens to be launched in the Scandinavian countries. Women at an increased risk of VTE should consider progestogen-only contraception or non-hormonal contraception.

Obstetric and neonatal risks among extremely macrosomic babies and their mothers.

OBJECTIVE: We estimated the risk of complications at birth of extremely large babies (≥5000 g). STUDY DESIGN: This was a cohort study including all births of extremely large babies in 1996 through 2005 and comparison cohort with normal birthweight (1:2) identified in the national birth registration. RESULTS: There were 343 extremely large babies or 0.9% of all singletons. Compared to the normal birthweight cohort (n = 679), there were increased odds of shoulder dystocia (odds ratio [OR], 26.9; 95% confidence interval [CI], 11.1-65.1), emergency cesarean section (OR, 5.2; 95% CI, 3.4-8.0), and failed labor induction (OR, 4.3; 95% CI, 1.7-11.0). The risk of elective section was not increased (OR, 1.1; 95% CI, 0.6-2.0). Minor congenital malformations were more frequent (OR, 2.1; 95% CI, 1.2-3.7), as were birth injuries (OR, 3.7; 95% CI, 2.1-6.8) and minor metabolic disturbance (OR, 2.5; 95% CI, 1.1-6.2), but not asphyxial births. CONCLUSION: The risk of shoulder dystocia for very large babies is markedly raised, as are minor complications, while for mothers the main risk is emergency section.

Pelvic endometriosis diagnosed in an entire nation over 20 years.

The annual incidence of pelvic endometriosis among women aged 15-49 years and up to age 69 years was ascertained for the Icelandic population between 1981 and 2000 by using Iceland's extensive record linkage systems. Comprehensive, state-financed health care and unique personal identification numbers enabled care to be tracked from first diagnosis. To identify cases, a centralized discharge-code registry was searched, as well as all hospital databases and, for individual patients, all hospital records. Each case of visually diagnosed and histologically verified endometriosis was cross-checked against the nationwide pathology registry. The revised American Society for Reproductive Medicine classification system was used for staging. Recorded was type of operation at diagnosis and presence of disease at 5 sites: deep pelvis, appendages, central pelvis, vesicouterine pouch, and ovaries. A total of 1,383 women were diagnosed surgically, with histologic verification of 811 (58.6%). All but 6 cases could be staged; 297 (36.9%) had minimal/mild and 508 (63.1%) had moderate/severe disease. The estimates of crude annual incidence were 0.1% for visually confirmed and 0.06% for histologically verified endometriosis, and respective age-standardized annual incidence was 0.1% and 0.05% for women aged 15-49 years. The most common site was the ovary, followed by deep pelvis, central pelvis, appendages, and vesicouterine pouch.