Karel Marsal

Intrauterine growth curves based on ultrasonically estimated foetal weights

Available standard intrauterine growth curves based on birthweights underestimate foetal growth in preterm period. New growth curves are presented based on data from four Scandinavian centres for 759 ultrasonically estimated foetal weights in 86 uncomplicated pregnancies. Mean weight of boys exceeded that of girls by 2‐3%. A uniform SD value of 12% of the mean weight was adopted for the standard curves as the true SD varied non‐systematically between 9.1 and 12.4%. Applied to an unselected population of 8663 singleton births, before 210 days of gestation, 32% of birthweights were classified as small‐for‐gestational age (SGA; i.e. below mean ‐2SD); the corresponding figures were 11.1% for gestational ages between 210 and 258 days, and 2.6% for ages of 259 days or longer. The new growth curves reveal better the true distribution of SGA foetuses and neonates, and are suggested for use in perinatological practice.

One-year survival of extremely preterm infants after active perinatal care in sweden

CONTEXT Up-to-date information on infant survival after extremely preterm birth is needed for assessing perinatal care services, clinical guidelines, and parental counseling. OBJECTIVE To determine the 1-year survival in all infants born before 27 gestational weeks in Sweden during 2004-2007. DESIGN, SETTING, AND PATIENTS Population-based prospective observational study of extremely preterm infants (707 live-born and 304 stillbirths) born to 887 mothers in 904 deliveries (102 multiple births) in all obstetric and neonatal units in Sweden from April 1, 2004, to March 31, 2007. MAIN OUTCOME MEASURES Infant survival to 365 days and survival without major neonatal morbidity (intraventricular hemorrhage grade >2, retinopathy of prematurity stage >2, periventricular leukomalacia, necrotizing enterocolitis, severe bronchopulmonary dysplasia). Associations between perinatal interventions and survival. RESULTS The incidence of extreme prematurity was 3.3 per 1000 infants. Overall perinatal mortality was 45% (from 93% at 22 weeks to 24% at 26 weeks), with 30% stillbirths, including 6.5% intrapartum deaths. Of live-born infants, 91% were admitted to neonatal intensive care and 70% survived to 1 year of age (95% confidence interval [CI], 67%-73%). The Kaplan-Meier survival estimates for 22, 23, 24, 25, and 26 weeks were 9.8% (95% CI, 4%-23%), 53% (95% CI, 44%-63%), 67% (95% CI, 59%-75%), 82% (95% CI, 76%-87%), and 85% (95% CI, 81%-90%), respectively. Lower risk of infant death was associated with tocolytic treatment (adjusted for gestational age odds ratio [OR], 0.43; 95% CI, 0.36-0.52), antenatal corticosteroids (OR, 0.44; 95% CI, 0.24-0.81), surfactant treatment within 2 hours after birth (OR, 0.47; 95% CI, 0.32-0.71), and birth at a level III hospital (OR, 0.49; 95% CI, 0.32-0.75). Among 1-year survivors, 45% had no major neonatal morbidity. CONCLUSION During 2004 to 2007, 1-year survival of infants born alive at 22 to 26 weeks of gestation in Sweden was 70% and ranged from 9.8% at 22 weeks to 85% at 26 weeks.

Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding — a Nordic multicenter study

OBJECTIVE The purpose of this study was to use transvaginal ultrasonographic measurements to find the thickness of the endometrium below which the risk of endometrial abnormality in women with postmenopausal bleeding is low. STUDY DESIGN This multicenter study was carried out at eight clinics in four Nordic countries. The study included 1168 women with postmenopausal bleeding scheduled for curettage Before the curettage was performed, the thickness of the endometrium was measured with transvaginal ultrasonography. The measurement included both endometrial layers (double-layer technique). The transvaginal ultrasonographic measurement was compared with the histopathologic diagnosis of the curettage specimens. RESULTS In women with atrophic endometrium the mean endometrial thickness (+/- SD) was 3.9 +/- 2.5 mm. The corresponding figures for women with endometrial cancer were 21.1 +/- 11.8 mm. No malignant endometrium was thinner than 5 mm. In 30 women (2.8%) it was not possible to measure the thickness of the endometrium; one of these women had endometrial cancer. The 95% confidence limit for the probability of excluding endometrial abnormality was 5.5% when the endometrial thickness was < or = 4 mm as measured by transvaginal ultrasonography. CONCLUSION The risk of finding pathologic endometrium at curettage when the endometrium is < or = 4 mm as measured by transvaginal ultrasonography is 5.5%. Thus in women with postmenopausal bleeding and an endometrium < or = 4 mm it would seem justified to refrain from curettage.

Cardiotocography only versus cardiotocography plus ST analysis of fetal electrocardiogram for intrapartum fetal monitoring: a Swedish randomised controlled trial

BACKGROUND Previous studies indicate that analysis of the ST waveform of the fetal electrocardiogram provides information on the fetal response to hypoxia. We did a multicentre randomised controlled trial to test the hypothesis that intrapartum monitoring with cardiotocography combined with automatic ST-waveform analysis results in an improved perinatal outcome compared with cardiotocography alone. METHODS At three Swedish labour wards, 4966 women with term fetuses in the cephalic presentation entered the trial during labour after a clinical decision had been made to apply a fetal scalp electrode for internal cardiotocography. They were randomly assigned monitoring with cardiotocography plus ST analysis (CTG+ST group) or cardiotocography only (CTG group). The main outcome measure was rate of umbilical-artery metabolic acidosis (pH <7.05 and base deficit >12 mmol/L). Secondary outcomes included operative delivery for fetal distress. Results were first analysed according to intention to treat, and secondly after exclusion of cases with severe malformations or with inadequate monitoring. FINDINGS The CTG+ST group showed significantly lower rates of umbilical-artery metabolic acidosis than the cardiotocography group (15 of 2159 [0.7%] vs 31 of 2079 [2%], relative risk 0.47 [95% CI 0.25-0.86], p=0.02) and of operative delivery for fetal distress (193 of 2519 [8%] vs 227 of 2447 [9%], 0.83 [0.69-0.99], p=0.047) when all cases were included according to intention to treat. The differences were more pronounced after exclusion of 291 in the CTG+ST group and 283 in the CTG group with malformations or inadequate recording. INTERPRETATION Intrapartum monitoring with cardiotocography combined with automatic ST-waveform analysis increases the ability of obstetricians to identify fetal hypoxia and to intervene more appropriately, resulting in an improved perinatal outcome.

Effectiveness and safety of the oxytocin antagonist atosiban versus beta-adrenergic agonists in the treatment of preterm labour

Objective To compare the effectiveness and safety of the oxytocin antagonist atosiban with conventional beta‐adrenergic agonist (beta‐agonist) therapy in the treatment of preterm labour.

Methodology and basic problems related to blood flow studies in the human fetus.

A method was developed for non-invasive measurement of human fetal blood flow. The method combines real-time ultrasonography with 2 MHz pulsed Doppler technique. The blood flow is calculated from the blood velocity, estimated from the Doppler spectrum, and the vessel diameter, measured in the real-time image. Time-distance recording was applied for measurements of the pulsatile diameter changes in the fetal aorta. The method proved to possess a good accuracy and reproducibility when tested in vitro experiments and in a comparison with electromagnetic flow measurements in animals. Possible sources of error were analysed and recommendations for minimizing the risk of errors are presented.

Incidence of and risk factors for neonatal morbidity after active perinatal care : extremely preterm infants study in Sweden (EXPRESS)

Aims:  The aim of this study was to determine the incidence of neonatal morbidity in extremely preterm infants and to identify associated risk factors.

Caesarean section on request: a comparison of obstetricians' attitudes in eight European countries

Objective  To explore the attitudes of obstetricians to performe a caesarean section on maternal request in the absence of medical indication.

Maternal anxiety in late pregnancy and fetal hemodynamics

The aim of this study was to investigate if fetal circulation is affected by maternal anxiety. 37 nulliparous women were studied prospectively in the third trimester of pregnancy, with self-rate tests of anxiety (STAI). Doppler ultrasound examination of the umbilical artery and fetal middle cerebral artery was performed at 37-40 gestational weeks. The pulsatility index (PI) was calculated and corrected for heart rate. The women were divided into groups of increasing levels of anxiety. The fetuses of women with high trait anxiety scores had significantly higher PI values in the umbilical artery (p = 0.0056), significantly lower PI values in the fetal middle cerebral artery (p = 0.0029) and significantly lower cerebro-umbilical PI ratios (p = 0.0002), suggesting a change in blood distribution in favor of brain circulation in the fetuses. Maternal weight, weight-increase, height, age, marital status, smoking habits, drinking habits and socio-economic factors known to affect fetal well-being did not interfere with these findings. No significant differences in birth-weight, length and head circumference were found between infants born to mothers with higher trait anxiety levels compared to mothers with lower trait anxiety levels. Our results suggest that maternal stress, in terms of trait anxiety, influences fetal cerebral circulation.

A high uterine artery pulsatility index reflects a defective development of placental bed spiral arteries in pregnancies complicated by hypertension and fetal growth retardation

INTRODUCTION The development of PIH is associated with a defective trophoblast invasion and conversion of spiral arteries into low-resistance uteroplacental arteries. Hypertension may then be a compensatory response to a defective uteroplacental perfusion. Similar mechanisms may operate in IUGR. AIM To compare uterine artery Doppler blood flow measurements with placental bed histology. The hypothesis was that placental bed vessel pathology plays a role for a raised flow resistance. MATERIALS AND METHODS After blood flow measurements, a placental bed biopsy was taken at CS in 26 complicated (study group) and 29 uncomplicated pregnancies (control group). RESULTS The uterine artery PI was significantly more often abnormally high in the study group compared with the control group, and also in hypertensive pregnancies compared with normotensive IUGR pregnancies. Physiological vessel changes were found in all controls but were absent in 76% of study cases. Physiological changes were significantly more often absent in SGA than in AGA newborns. Absence of physiological changes were significantly more often found in cases with an abnormally high PI. DISCUSSION The results link together circulatory and structural pathophysiological changes of the uteroplacental unit. A defective physiological conversion of the spiral arteries was associated with an increased uterine flow resistance. CONCLUSION This study gave further support for the existence of a triad of defective placental bed vessel maturation, increased uteroplacental flow resistance, and hypertension.