Malin Thorsell

Expected day of delivery from ultrasound dating versus last menstrual period—obstetric outcome when dates mismatch

Objective  To analyse the association between fetal size at time of dating ultrasound and risk for preterm delivery and small‐for‐gestational‐age (SGA) birth and to evaluate if timing of ultrasound, that is before 14 weeks of gestation or after 16 weeks affects this association.

Cesarean delivery and risk for postoperative adhesions and intestinal obstruction: a nested case-control study of the Swedish Medical Birth Registry

OBJECTIVE The objective of the study was to estimate the risk for postoperative adhesions and intestinal obstruction after cesarean delivery and to estimate whether the rate remains stable over time. STUDY DESIGN Women who had the aforementioned diagnoses in the Swedish Hospital Discharge Registry were linked to the Swedish Medical Birth Registry. Women with diagnoses increasing the risk for adhesions were excluded. More than 900,000 women were investigated. Risks were calculated and were adjusted for age, parity, body mass index, and smoking. RESULTS Women delivered by cesarean delivery had an increased risk of adhesions: adjusted odds ratio, 2.1 (95% confidence interval, 1.8-2.4) and intestinal obstruction: adjusted odds ratio, 2.0 (95% confidence interval, 1.7-2.4). The number needed to harm was 360. Multiple caesarean deliveries increased the risk of adhesions. The risk did not increase over time. CONCLUSION The absolute risk of postoperative adhesions and intestinal obstruction after cesarean section are low but should be included when counseling women requesting cesarean delivery.

Intrahepatic cholestasis of pregnancy and cancer, immune-mediated and cardiovascular diseases: A population-based cohort study

BACKGROUND & AIMS Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease in pregnancy. It is associated with hepatobiliary diseases that might predispose to cancer and also with gestational diabetes and preeclampsia. In this study, we examined associations between ICP and cancer, and immune-mediated and cardiovascular diseases. METHODS By linking the Swedish Medical Birth Register and the Swedish Patient Register, we identified 11,388 women with ICP and 113,893 matched women without ICP who gave birth between 1973 and 2009. Diagnoses of cancer and immune-mediated and cardiovascular diseases both before and after delivery were obtained from the Patient Register. The main outcome measures were hazard ratios (HRs), calculated through Cox regression, for the indicated diseases after delivery. RESULTS ICP was not associated with later overall cancer (HR 1.07, 95% confidence interval [CI] 0.94-1.21), but it was associated with later liver and biliary tree cancer (HR 3.61, 95% CI 1.68-7.77, and 2.62, 95% CI 1.26-5.46, respectively). ICP was also associated with later immune-mediated diseases (HR 1.28, 95% CI 1.19-1.38), and specifically diabetes mellitus (HR 1.47, 95% CI 1.26-1.72), thyroid disease (HR 1.30, 95% CI 1.14-1.47), psoriasis (HR 1.27, 95% CI 1.07-1.51), inflammatory polyarthropathies (HR 1.32, 95% CI 1.11-1.58) and Crohns disease (HR 1.55, 95% CI 1.14-2.10), but not ulcerative colitis (HR 1.21, 95% CI 0.93-1.58). Women with ICP also had a small increased risk of later cardiovascular disease (HR 1.12, 95% CI 1.06-1.19). CONCLUSIONS Women with ICP have increased risk of later hepatobiliary cancer and immune-mediated and cardiovascular diseases.

Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women.

Objective. To assess the risk for emergency cesarean section among women in whom labor was induced in gestational week ≥41 and to evaluate if parity and mode of induction affected this association. Design. Hospital‐based retrospective cohort study. Population. Singleton pregnancies delivered after ≥41 gestational weeks at Danderyd Hospital, Stockholm, Sweden, during 2002–2006. Material and methods. Of 23 030 singleton pregnancies meeting the entry criteria, 881 were induced with a Bishop score of <7. Obstetric outcome was assessed through linkage with the Swedish Medical Birth Registry and a local obstetrical database containing information from patients’ medical files. Results were adjusted for body mass index, age and the use of epidural analgesia. Main outcome measure. Risk for emergency cesarean section. Results. Among women who were induced, the proportions delivered by emergency cesarean section were 42% for nulliparous and 14% for multiparous. Compared to spontaneous onset, this corresponded to a more than threefold increase in risk for nulliparous women (OR 3.34, 95%CI 2.77–4.04) and an almost twofold increase in risk for multiparous women (OR 1.94, 95%CI 1.24–3.02). There was no significant difference in risk for emergency cesarean section between the two methods of induction (PGE2 and transcervical catheter). Conclusions. Compared to spontaneous onset of delivery, induction of labor is associated with an increased risk for emergency cesarean section both among nulliparous and multiparous women. When labor is induced, the high risk for emergency cesarean must be kept in mind.

Caesarean section and risk for endometriosis: a prospective cohort study of Swedish registries

To investigate the association between caesarean section and later endometriosis.

Stereological assessment of placental morphology in intrahepatic cholestasis of pregnancy

OBJECTIVE To apply stereology for the detection of possibly morphological abnormalities in placentas of women with intrahepatic cholestasis of pregnancy (ICP). STUDY DESIGN Prospective case-control study of placentas from untreated and UDCA-treated ICP, respectively, and normal pregnancies, examined for morphological differences by systematic random sampling generated by computerized stereology methodology. MAIN OUTCOME MEASURES Volume of placenta, surface area of terminal villi and capillaries, volume fraction of collagen, number of syncytial knots, and chorangiosis. RESULTS Surface area of terminal villi and capillaries, and number of syncytial knots were higher in placentas from all ICP, as compared to controls (p < 0.01). A reduction of collagen was found in placentas from UDCA-treated ICP, both in comparison to placentas from untreated ICP and controls (p < 0.05). CONCLUSION ICP affects the placenta morphologically as shown by increased terminal villous and capillary surface area, and number of syncytial knots.

Risks of emergency cesarean section and fetal asphyxia after induction of labor in intrahepatic cholestasis of pregnancy: a hospital-based retrospective cohort study.

OBJECTIVES Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy liver-specific disease. Induction of labor in gestational weeks 37-39 is commonly performed with the perspective to avoid the complication of stillbirth. We aimed to study whether this practice increases the risks of emergency cesarean section (CS) and fetal asphyxia. STUDY DESIGN We assessed the risk of emergency CS and fetal asphyxia in ICP among women with spontaneous and induced onset of labor in comparison to women without ICP. We performed a hospital based retrospective cohort study with 25,870 singleton pregnancies, 333 with ICP (1.3%), of which 231 gave birth in weeks 37-39. Obstetric outcome was assessed through linkage of the Swedish Medical Birth Registry and a local obstetrical database based on the patients medical files. MAIN OUTCOME MEASURE Risk for emergency CS; fetal asphyxia and postpartum hemorrhage. RESULTS The risk of emergency CS in ICP with spontaneous onset of labor (12.5%) did not differ from non ICP women with spontaneous onset of labor (9.3%; aOR, 1.33; 95% CI 0.60-2.96). When labor was induced, risk of emergency CS was significantly lower among women with ICP than among without ICP (aOR, 0.47; 95% CI 0.26-0.86). Exclusion of women with preeclampsia, gestational hypertension or diabetes mellitus did not alter the result. The risk for fetal asphyxia was not significantly associated with ICP status. CONCLUSION Induction of labor in women with ICP gestational weeks 37-39 did not increase the risks of emergency CS or fetal asphyxia.

Longitudinal study of vascular structure and function during normal pregnancy

To examine alterations in maternal vascular structure and function during normal pregnancy.

Large fetal size in early pregnancy associated with macrosomia

To assess if fetal size at the time of ultrasound dating examination is associated with the risk of macrosomia and complications associated with macrosomia.

Evaluation of stationary colposcope and the Gynocular, by the Swede score systematic colposcopic system in VIA positive women: a crossover randomized trial.

Objective This study aimed to evaluate cervical lesions by the Swede coloscopy system, histologic finding, liquid-based cytology, and human papillomavirus (HPV) in women who resulted positive for visual inspection of the cervix with acetic acid (VIA) by using a pocket-sized battery-driven colposcope, the Gynocular (Gynius AB, Sweden). Methods This study was a crossover, randomized clinical trial at the colposcopy clinic of Bangabandhu Sheikh Mujib Medical University in Dhaka, Bangladesh, with 540 VIA-positive women. Swede scores were obtained by the Gynocular and stationary colposcope, as well as samples for liquid-based cytology, HPV, and cervical biopsies. The Swede scores were compared against the histologic diagnosis and used as criterion standard. The percentage agreement and the κ statistic for the Gynocular and standard colposcope were also calculated. Results The Gynocular and stationary colposcope showed high agreement in Swede scores with a κ statistic of 0.998, P value of less than 0.0001, and no difference in detecting cervical lesions in biopsy. Biopsy detected cervical intraepithelial neoplasia (CIN) 2+ (CIN2, CIN3, and invasive cancer) in 38 (7%) of the women, whereas liquid-based cytology detected CIN2+ in 13 (2.5%) of the women. Forty-four (8.6%) women who were tested resulted positive for HPV; 20 (3.9%) women had HPV-16, 2 (0.4%) had HPV-18, and 22 (4.3%) had other high-risk HPV. Conclusions Our study showed that few VIA-positive women had CIN2+ lesions or HPV infection. Colposcopy by Swede score identified significantly more CIN2+ lesions than liquid-based cytology and could offer a more accurate screening and selection for immediate treatment of cervical lesions in low-resource settings.