Bjørn Backe

Third degree obstetric tears; outcome after primary repair.

BACKGROUND: Disruption of the anal sphincter occurs in 0.5 to 2.5% of women during delivery. Defects of the sphincter are major causes of fecal incontinence. More than 30% of women who suffer from third degree perineal tears develop incontinence. We sought to determine the incidence of symptoms and injury to the anal sphincter among women who gave birth during a 5 year period. We also investigated the sensitivity of manometry and endosonography as well as the correlation of these two diagnostic modalities. METHODS: Thirty-eight women were examined one to five years after delivery. We used a questionnaire to assess symptoms of anal incontinence. Anal manometry and endosonography were performed. RESULTS: Twenty (57%) women had symptoms; most of them (34%) in the form of flatulence incontinence. The rest were incontinent of either liquid or solid stools. Four of these women were re-operated. Seventeen percent of the women suffered from anal incontinence during sexual intercourse. Only seven women had been in contact with a doctor regarding these problems. CONCLUSION: The fact that 57% of the women that took part in this study reported complications, leads us to the conclusion that the primary repair of third degree anal sphincter tears is unsatisfactory. It is important to decide whether any changes in primary repair may improve results in the future. Sexual dysfunction is also a complication of third degree obstetric tear with primary repair. It is important that the women who suffer from anal sphincter tear, as well as doctors, are given information about possible symptoms and the treatment available.

Physical abuse and low birthweight: a case‐control study

Objective To examine whether physical abuse of a woman by her partner was associated with low birthweight.

A 12-week randomised study comparing intravenous iron sucrose versus oral ferrous sulphate for treatment of postpartum anemia

Objective. To analyze the effect of intravenous ferrous sucrose compared with oral ferrous sulphate on hematological parameters and quality of life in women with postpartum anemia. Design. Open randomised controlled trial. Setting. Multicentre study comprising five obstetrical departments in Norway. Population. Hundred and twenty‐eight postpartum women with hemorrhagic anemia (Hb between 6.5 g/100 ml and 8.5 g/100 ml). The intervention group (59 women) received 600 mg iron sucrose intravenously followed by 200 mg iron sulphate daily from week 5. The control group (70 women) were given 200 mg iron sulphate daily. Methods. Randomisation and start of treatment occurred within 48 hours of the delivery. Participants were followed up at 4, 8 and 12 weeks. Main outcome measures. Hemoglobin, ferritin and quality of life assessed with the Medical Outcomes Study Short Form 36 (SF‐36) and the Fatigue Scale. Results. After 4 weeks the mean hemoglobin values in both groups were similar (11.9g/100ml vs. 12.3g/100ml, p = 0.89). The mean serum ferritin value after 4 weeks was significantly higher in the intervention group with 13.7μg/L vs. 4.2μg/L in the control group (p<0.001). At 8 and 12 weeks the hematological parameters were similar. The total fatigue score was significantly improved in the intervention group at week 4, 8 and 12, whereas SF‐36 scores did not differ. Conclusion. Women who received 600mg intravenous iron sucrose followed by standard oral iron after four weeks, replenished their iron stores more rapidly and had a more favorable development of the fatigue score indicating improved quality of life.

Obstetric brachial plexus palsy: A birth injury not explained by the known risk factors

Objective. To determine the incidence and prognosis of obstetric brachial plexus injuries and analyze associated risk factors. Design. Analysis of prospectively collected information comprising all births from 1991 to 2000, with complete follow‐up of affected children. Setting. St Olavs University Hospital, a tertiary care hospital in the middle part of Norway. Population. Thirty thousand five hundred and seventy‐four children; all were examined within 24 hours of birth and 91 were diagnosed with brachial plexus injury. Methods. We reviewed the hospital records and analyzed the data submitted from our hospital to the Medical Birth Register of Norway. Result. Risk factors are shoulder dystocia, macrosomy, diabetes, vacuum extraction and forceps delivery. The predictive power of these variables is poor. Almost half of the plexus injuries followed spontaneous vaginal deliveries with second stage of 30 minutes or less. Two newborns were delivered by cesarean section and two were vaginal breech deliveries. In 15 children (0.5/1,000) a permanent plexus injury has been diagnosed. Compared with transient plexus impairment, risk factors for a permanent injury were high maternal body mass index, shoulder dystocia, fractured humerus and fetal asphyxia. Fracture of the clavicle was significantly more frequent when the injury was transient, possibly reflecting a protective effect. Conclusion. The incidence of obstetric brachial plexus injury is 0.3% and the recovery rate is 84%, resulting in 0.5 permanent injuries per 1,000 births. Plexus injury is not well predicted by known risk factors. Other etiological factors should be sought.

Adverse obstetric outcome in fetuses that are smaller than expected at second trimester routine ultrasound examination

Background.  Adverse obstetric outcome in fetuses that are smaller than expected at second trimester routine ultrasound examination.

Restless legs syndrome in pregnancy is a frequent disorder with a good prognosis

The aim of this study was to assess the prevalence of restless legs syndrome in pregnancy. We distributed a questionnaire to 541 consecutive postpartum patients and received answers from 251 (46%) women. Of the participants, 34% reported restless legs syndrome in pregnancy. In 97% of the women in whom restless legs syndrome had started during the pregnancy, the symptoms disappeared within two to three days after delivery. There was no correlation between pregnancy‐related restless legs syndrome and low hemoglobin levels in the first trimester, and the incidence of restless legs syndrome was not affected by use of iron supplementation. We conclude that in our population, restless legs syndrome in pregnancy is both frequent and transient, occurring in approximately one in three pregnancies and typically resolving within a few days after delivery.

Overutilization of antenatal care in Norway

Background: It has long been a common belief in Norway that all pregnant women attend antenatal care, but no documentation has been provided. In 1984, official guidelines were issued recommending a reduction of the number of routine visits. However, no studies have been performed in order to monitor whether the recommendations are followed. Aims: Utilization review of antenatal care in Norway. Method: A national cross-sectional study, comprising all deliveries in all obstetrical units in the country during a two-week registration period in June 1996. Information on onset of antenatal care, the number of visits, parity and gestational age at the time of delivery was collected. The study comprised 1,557 deliveries; 45 of the 60 obstetrical units in the country participated. Results: The mean number of antenatal visits was 12.2. Only two of the 1,557 women (0.1%) delivered without any previous antenatal care. A total of 80% started antenatal care in the first trimester, 0.4% had their first antenatal visit in the third trimester. The mean number of antenatal visits was substantially higher than the recommended number. Conclusion: Antenatal care-providers do not comply with the official guidelines.

Maternal left ventricular and endothelial functions in preeclampsia.

Objective. To compare maternal left ventricular and endothelial functions in preeclampsia and normal pregnancy, during pregnancy and after delivery. Design. Observational study with follow‐up. Setting. University hospital and midwife‐led antenatal care center. Samples. Twenty untreated women with preeclampsia and 20 women with normal pregnancy, matched for gestational age and parity. Methods. The women were examined during pregnancy and three months after delivery. Left ventricular function was assessed by echocardiography, including tissue‐Doppler imaging. Endothelial function was assessed by measuring flow‐mediated dilation of the brachial artery. Main outcome measures. Early diastolic mitral annular tissue velocity, “e”, peak systolic tissue velocity, “S”, and flow‐mediated dilation. Results. The diastolic function was reduced in preeclampsia, with lower “e”, and there was a higher ratio of early diastolic mitral inflow velocity and early diastolic mitral annular velocity, “E/e”. Early diastolic mitral inflow deceleration time and isovolumetric relaxation time were similar between the groups, suggesting pseudonormalization and increased filling pressures in preeclampsia. “S” was lower in the preeclampsia group during pregnancy. Both diastolic and systolic left ventricular functions normalized postpartum. The flow‐mediated dilation was impaired in the preeclampsia group both during pregnancy and three months after delivery. Conclusions. The maternal left ventricular function was impaired during preeclampsia but had normalized three months after delivery. The endothelial function, measured by flow‐mediated dilation, was impaired in the preeclampsia group as compared with the normal pregnancy group both during pregnancy and three months after delivery.

Maternal smoking and age Effect on birthweight and risk for small-for-gestational age births

Study objective. To analyse the information on maternal smoking routinely recorded during antenatal care by general practitioners, with emphasis on the impact of smoking on birth weight and risk for small‐for‐gestational age (SGA) births. Design. Geographically based cohort study.

Pregnancy risk increases from 41 weeks of gestation.

Background. The aim of this study was to evaluate the mortality and morbidity of conservatively managed post‐term pregnancies (gestation 294 days and beyond). Materials and methods. This is a population‐based prospective study. The sample was comprised of all women (N=17 493) with a singleton pregnancy in one Norwegian county from 1989 to 1999, with a second‐trimester ultrasound examination and delivery after 37 completed gestational weeks. Results. One thousand three hundred and thirty‐six (7.6%) of the deliveries were post‐term. In this group, the increase in perinatal mortality reached borderline significance [relative risk (RR) 2.0; 95% confidence interval 0.9–4.6]. Perinatal morbidity expressed as Apgar score <7 at 5min (RR 2.0; 95% confidence interval 1.2–3.3), and transferal to neonatal intensive care unit (RR 1.6; 95% confidence interval 1.3–2.0) were significantly more frequent. However, RR for perinatal death calculated per 1000 ongoing pregnancies increased significantly from 0.2 in week 37–3.7 in week 42, using perinatal mortality in gestational week 41 as a reference. Conclusions Our results indicate that expectant management of post‐term pregnancies allowing pregnancies to continue up to week 43 carries a risk for perinatal mortality and morbidity. The risk increases already from gestational week 41. The guidelines for management of post‐term pregnancies should be revised.