Inger Økland

Prediction of labor and delivery by transperineal ultrasound in pregnancies with prelabor rupture of membranes at term

To evaluate whether engagement of the fetal head or cervical length in women with premature rupture of membranes (PROM) at term, are associated with time from PROM to delivery or need for operative delivery.

Is there an increase of postpartum hemorrhage, and is severe hemorrhage associated with more frequent use of obstetric interventions?

Objective. To analyze changes in postpartum hemorrhage over a 10‐year period from 1998 to 2007, and to explore factors associated with severe hemorrhage. Design. Retrospective cohort study, prospectively collected information. Setting. Stavanger University Hospital, a secondary referral center, Norway. Population. An unselected population of 41,365 women giving birth at the hospital. Methods. We analyzed changes over time in mean postpartum hemorrhage, severe postpartum hemorrhage and associated factors. Estimated blood loss >1,000 ml was defined as severe hemorrhage. Data were collected from the hospitals database. Main outcome measures. Severe postpartum hemorrhage and obstetric interventions. Results. We observed an increase in severe hemorrhage during the study period. After cesarean sections, the risk of severe hemorrhage was twice the risk of severe hemorrhage after vaginal deliveries (5.9%; 95% CI 5.3–6.6 vs. 2.8%; 95% CI 2.6–2.9). The most important factors associated with severe hemorrhage following vaginal deliveries were twin deliveries (OR 6.8), retained placenta (OR 3.9) and inductions of labor (OR 2.2). For cesarean sections, twin deliveries had the strongest association with severe hemorrhage (OR 3.7) followed by general anesthesia (OR 3.0). Obstetric interventions became more frequent; elective cesarean sections increased from 2.4 to 4.9%, acute cesarean sections from 5.5 to 8.9%, operative vaginal deliveries from 9.3 to 12.5%, inductions of labor from 14.3 to 15.8% and augmentations of labor from 5.8 to 29.3%. Conclusions. The incidence of severe postpartum hemorrhage increased, and this may be related to more frequent use of obstetric interventions.

Ultrasound assessment of fetal head–perineum distance before induction of labor

To evaluate fetal head–perineum distance measured by ultrasound imaging as a predictive factor for induction of labor, and to compare this distance with maternal factors, the Bishop score and ultrasound measurements of cervical length, cervical angle and occiput position.

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.

Prevalence of Low Back and Pelvic Pain During Pregnancy in a Norwegian Population

OBJECTIVE The purpose of this study was to investigate the cumulative prevalence of low back pain (LBP), pelvic pain (PP), and lumbopelvic pain during pregnancy, including features possibly associated with development of pregnancy-related PP, in an unselected population of women. METHODS A retrospective cohort study was conducted in which all women giving birth at Stavanger University hospital in a 4-month period were asked to participate and to fill in a questionnaire on demographic features, pain, disability, and Oswestry Disability Index. Inclusion criteria were singleton pregnancy of at least 36 weeks and competence in the Norwegian language. RESULTS Nearly 50% of the women experienced moderate and severe PP during pregnancy. Approximately 50% of them had PP syndrome, whereas the other half experienced lumbopelvic pain. Ten percent of the women experienced moderate and severe LBP alone. These pain syndromes increased sick leave and impaired general level of function during pregnancy. Approximately 50% of women with PP had pain in the area of the symphysis. The analysis of risk factors did not present a unidirectional and clear picture. CONCLUSIONS Pelvic pain in pregnant women is a health care challenge in which moderate and severe pain develops rather early and has important implications for society. The observed associations between possible causative factors and moderate and severe LBP and PP in this study may, together with results from other studies, bring some valuable insights into their multifactorial influences and provide background information for future studies.

Can ultrasound measurements replace digitally assessed elements of the Bishop score

Objective. To compare elements of the Bishop score and corresponding sonographic measurements before induction of labor, and assess how predictive factors can be used in a clinical setting. Design. Prospective comparative clinical study. Setting. Secondary referral center, university hospital. Population. A total of 275 women scheduled for induction of labor. Methods. Fetal head descent to the perineum was assessed with transperineal ultrasound. Cervical length, posterior angle, and dilatation were evaluated with transvaginal ultrasound followed by Bishop score without knowledge of the ultrasound measurements. Results. Univariable regression analyses of successful induction were significant for digital assessment of cervical dilatation, ultrasound measured fetal head–perineum distance ≤40 mm, ultrasound measured cervical length ≤25 mm, and ultrasound measured posterior cervical angle >90 degrees. After adjusting for maternal factors in a multivariable model, estimates were significant for previous vaginal birth (OR 5.3; 95% CI 2.1–13.9, p<0.01), but borderline for maternal height (OR 1.1; 95% CI 1.0–1.2, p = 0.01) and ultrasound measured posterior cervical angle >90 degrees (OR 2.6; 95% CI 1.1–6.1, p = 0.03). A scoring model combining ultrasound measured fetal head–perineum distance, cervical length, cervical posterior angle and digitally assessed cervical dilatation, discriminated successful and failed induction at 71% (95% CI 61–80%, p<0.01) area under the receiver–operating characteristics curve. Conclusion. Digital assessment of fetal head descent, cervical length and position can possibly be replaced with ultrasound measurements. Dilatation is best evaluated with digital assessment. Combination of these four factors can predict success of labor induction.

A population-based study of associations between preeclampsia and later cardiovascular risk factors.

OBJECTIVE Women with a history of preeclampsia are at increased lifetime risk for cardiovascular disease. Their offspring may carry similar risks. The aim was to study cardiovascular and metabolic risk factors 11 years after the delivery among women who were diagnosed with mild, moderate, or severe preeclampsia, and their offspring, compared with women without preeclampsia and their offspring. STUDY DESIGN In a follow-up 11 years after a nested case-control study at birth, we studied 611 mother-offspring dyads, including 228 dyads with preeclampsia in the index pregnancy and 383 dyads without preeclampsia. Cardiovascular and metabolic risk profiles were assessed by serum lipids (total cholesterol, high-density lipoprotein [HDL] cholesterol, non-HDL cholesterol), insulin-related factors (glucose, insulin, and homeostasis assessment model for insulin resistance) and blood pressure in mothers and children. RESULTS Among mothers with mild or moderate preeclampsia, levels of glucose, insulin, and homeostasis assessment model for insulin resistance were higher than in the nonpreeclampsia group and also higher compared with mothers with severe preeclampsia (all P < .05). HDL cholesterol was lower in mothers with mild or moderate preeclampsia (all P < .05), but other lipids did not substantially differ between the groups. Body mass index and blood pressure (systolic and diastolic) were also higher in the mild and moderate preeclampsia group compared with mothers without preeclampsia (all P < .05). Among the offspring, we found no clear differences in any blood analytes between the groups. CONCLUSION Women with a previous diagnosis of mild or moderate, but not severe, preeclampsia may have an adverse metabolic and cardiovascular risk profile 11 years after the delivery.

A randomized prospective study of misoprostol and dinoproston for induction of labor

Background. Misoprostol, a prostaglandin E1 analog registered for the prevention of gastric ulcers in NSAID‐drug users, has been reported to be more effective for labor induction than the standard prostaglandin, dinoproston after vaginal application. There have been some concerns about possible hyperstimulation of the uterine activity and about the safety for the fetus with this new drug.

Narrowed beam width in newer ultrasound machines shortens measurements in the lateral direction: fetal measurement charts may be obsolete.

Fetal ultrasound measurements are made in axial, lateral and oblique directions. Lateral resolution is influenced by the beam width of the ultrasound system. To improve lateral resolution and image quality, the beam width has been made narrower; consequently, measurements in the lateral direction are affected and apparently made shorter, approaching the true length. The aims of this study were to explore our database to reveal time‐dependent shortening of ultrasound measurements made in the lateral direction, and to assess the extent of beam‐width changes by comparing beam‐width measurements made on old and new ultrasound machines.

Advantages of the population-based approach to pregnancy dating: results from 23,020 ultrasound examinations.

To confirm the results from two previous evaluations of term prediction models, including two sample‐based models and one population‐based model, in a third population.