Nonna Heiskanen

Under-attending free antenatal care is associated with adverse pregnancy outcomes

BackgroundMost pertinent studies of inadequate antenatal care concentrate on the risk profile of women booking late or not booking at all to antenatal care. The objective of this study was to assess the outcome of pregnancies when free and easily accessible antenatal care has been either totally lacking or low in number of visits.MethodsThis is a hospital register based cohort study of pregnancies treated in Kuopio University Hospital, Finland, in 1989 – 2001. Pregnancy outcomes of women having low numbers (1–5) of antenatal care visits (n = 207) and no antenatal care visits (n = 270) were compared with women having 6–18 antenatal visits (n = 23137). Main outcome measures were: Low birth weight, fetal death, neonatal death. Adverse pregnancy outcomes were controlled for confounding factors (adjusted odds ratios, OR: s) in multiple logistic regression models.ResultsOf the analyzed pregnant population, 1.0% had no antenatal care visits and 0.77% had 1–5 visits. Under- or non-attendance associated with social and health behavioral risk factors: unmarried status, lower educational level, young maternal age, smoking and alcohol use. Chorio-amnionitis or placental abruptions were more common complications of pregnancies of women avoiding antenatal care, and pregnancy outcome was impaired. After logistic regression analyses, controlling for confounding, there were significantly more low birth weight infants in under- and non-attenders (OR:s with 95% CI:s: 9.18 (6.65–12.68) and 5.46 (3.90–7.65), respectively) more fetal deaths (OR:s 12.05 (5.95–24.40) and 5.19 (2.04–13.22), respectively) and more neonatal deaths (OR:s 10.03 (3.85–26.13) and 8.66 (3.59–20.86), respectively).ConclusionEven when birth takes place in hospital, non- or under-attendance at antenatal care carries a substantially elevated risk of severe adverse pregnancy outcome. Underlying adverse health behavior and possible abuse indicate close surveillance of the newborn.

Transition from overweight to obesity worsens pregnancy outcome in a BMI-dependent manner.

Objective: To assess pregnancy outcomes in different BMI groups.

Marriage still protects pregnancy

Objective  To assess the risk factors and outcome of pregnancy outside marriage in the 1990s, in conditions of a high percentage of extramarital pregnancies and high standard maternity care, used by the entire pregnant population.

Fetal Macrosomia – A Continuing Obstetric Challenge

Background: Macrosomic fetuses represent a continuing challenge in obstetrics. Objectives: We studied maternal risk factors of fetal macrosomia and maternal and infant outcome in such cases. Methods: A retrospective cohort study was carried out with a total of 26,961 singleton pregnancies between 1989 and 2001. Records of 886 mothers who gave birth to live born infants weighing ≧4,500 g were compared to those of 26,075 mothers with normal weight (<4,500 g) infants. Multiple regression analysis was used to identify independent reproductive risk factors. Perinatal complications were also assessed. Results: The incidence of fetal macrosomia was 3.4%. Diabetes, previous macrosomic birth, postdatism (>42 weeks of gestation), obesity (BMI > 25 before pregnancy), male infant, gestational diabetes mellitus, and non-smoking were independent risk factors of fetal macrosomia, with adjusted risks of 4.6, 3.1, 3.1, 2.0, 1.9, 1.6, 1.4, respectively. In the macrosomic group, birth and maternal traumas occurred significantly more often than in the control group. However, records of subsequent pregnancies (n = 250) after the study period showed that a previous uncomplicated birth appeared to decrease complication risks. Conclusions: Most cases of fetal macrosomia occur in low-risk pregnancies and evaluation of maternal risks cannot accurately predict which women will eventually give birth to an overweight newborn. After an uncomplicated birth of a macrosomic infant, vaginal delivery may be a safe option for the infant and mother.

Obstetric outcome in post-term pregnancies: time for reappraisal in clinical management

Background. The objective of this study was to determine the outcome of pregnancy in post‐term cases compared with term cases in a well defined population receiving modern obstetric care. Methods. We utilized the population‐based birth registry data of the Kuopio University Hospital (1990–2000) to investigate pregnancy outcome in 1,678 post‐term singleton pregnancies. The general obstetric population (n=22,712) was used as a reference group in logistic regression analysis. Results. The overall frequency of post‐term pregnancies was 6.9% and the incidence of post‐term pregnancies was found to be increased in obese, primiparous, and smoking women, whereas in women with chronic diseases and obstetric risks deliveries were induced earlier. The risks of macrosomia, maternal complications, and operative deliveries were increased in post‐term pregnancies. Post‐term infants experienced meconium passage (21.2% versus 12.8%) (p<0.01) and intrapartum asphyxia (3.4% versus 2.1%) (p<0.01) significantly more often than the controls. However, the stillbirth rate was low, probably due to careful monitoring of these pregnancies. Conclusions. Although high‐risk pregnancies were not allowed to come post‐term, postmaturity per se is a moderate risk state compromising fetal well‐being with regard to meconium passage and acid–base status at birth. We conclude that simple antenatal monitoring beyond 42 weeks reduces perinatal mortality but is inefficient in reducing meconium‐stained liquor seen with increasing gestation.

Does unemployment in family affect pregnancy outcome in conditions of high quality maternity care

BackgroundThe influence of unemployment in the family on pregnancy outcome is controversial. Only a few studies have involved investigation of the effect of unemployment of the father on pregnancy. The objective of this study was to assess the effects of unemployment of one or both parents on obstetric outcome in conditions of free antenatal care attended by the entire pregnant population.MethodsThe data of 24 939 pregnancies included maternal risk factors, pregnancy characteristics and outcome, and was based on a self administered questionnaire at 20 weeks of pregnancy and on clinical records.ResultsUnemployment was associated with adolescent maternal age, unmarried status and overweight, anemia, smoking, alcohol consumption and prior pregnancy terminations. Multivariate logistic regression analysis indicated that after controlling for these maternal risk factors small differences only were found in pregnancy outcomes between unemployed and employed families. Unemployed women had significantly more often small-for-gestational-age (SGA) infants, at an OR of 1.26 (95% CI: 1.12 – 1.42) whereas, in families where both parents were unemployed, the risk of SGA was even higher at an OR of 1.43 (95% CI: 1.18 – 1.73). Otherwise, pregnancy outcome was comparable in the groups studied.ConclusionFree antenatal care was unable to fully overcome the adverse pregnancy outcomes associated with unemployment, SGA risk being highest when both parents are unemployed.

Subtle changes in ADMA and l-arginine concentrations in normal pregnancies are unlikely to account for pregnancy-related increased flow-mediated dilatation.

Background:  Our objective was to investigate whether serum concentrations of asymmetric dimethylarginine (ADMA) or l‐arginine correlate to hyperlipidemia or endothelial function in normal pregnancy compared with the non‐pregnant subjects.

Placenta percreta: methotrexate treatment and MRI findings.

Our patient was a 24-year-old gravida 2 para 0 woman. After delivery, placenta percreta was noticed. There was no postpartum hemorrhage, and the patient desired future pregnancies. Although placenta percreta is rare, its sequelae include potentially lethal hemorrhage and loss of reproduction function. Placenta percreta was confirmed histologically and with ultrasonography and magnetic resonance imaging (MRI). Placenta percreta was treated conservatively with methotrexate. On follow-up, MRI showed a small calcified transmural extension of the placenta throughout the uterus in the right fundal area. Color Doppler ultrasonography showed no blood flow in the corresponding area, and maternal serum human chorionic gonadotropin (hCG) was undetectable. Use of MRI is a new method to detect abnormal placentation, and it could be used on follow-up in selective cases with other follow-up modalities. However, it seems likely that conservative management to preserve future fertility remains a secured and reasonable alternative when a patient has no active bleeding.

Flow mediated vasodilation and circulating concentrations of high sensitive C-reactive protein, interleukin-6 and tumor necrosis factor-α in normal pregnancy – The Cardiovascular Risk in Young Finns Study

Background:  Traditional risk factors such as hyperlipidemia induce a state of inflammation that impairs vascular function. Despite marked maternal hyperlipidemia, endothelial function improves during pregnancy. In non‐pregnant state increased circulating levels of pro‐inflammatory cytokines and high sensitive C‐reactive protein (hsCRP) lead to attenuated flow mediated vasodilation. Relation between endothelial function and pro‐inflammatory cytokines has not been studied thoroughly in pregnancy. The aim of this study was to evaluate the effect of pregnancy on hsCRP and pro‐inflammatory cytokines and their associations with vascular endothelial function.

Blood pressure and heart rate variability analysis of orthostatic challenge in normal human pregnancies.

The aim of the present study was to evaluate pregnancy‐related changes in autonomic regulatory functions in healthy subjects. We studied cardiovascular autonomic responses to head‐up tilt (HUT) in 28 pregnant women during the third trimester of pregnancy and 3 months after parturition. The maternal ECG and non‐invasive beat‐to‐beat blood pressure were recorded in the horizontal position (left‐lateral position) and during HUT in the upright position. Stroke volume was assessed from blood pressure signal by using the arterial pulse contour method. Heart rate variability (HRV) was analysed in frequency domain, and baroreflex sensitivity by the cross‐spectral and the sequence methods. In the horizontal position, all frequency components of HRV were lower during pregnancy than 3 months after parturition (P < 0·01 to <0·001), while pregnancy had no influence on normalized low frequency and high frequency powers. During pregnancy haemodynamics was well balanced with only minor changes in response to postural change while haemodynamic responses to HUT were more remarkable after parturition. In pregnant women HRV and especially its very low frequency component increased in response to HUT, whereas at 3 months after parturition the direction of these changes was opposite. Parasympathetic deactivation towards term is likely to contribute to increased heart rate and cardiac output at rest, whereas restored sympathetic modulation with modest responses may contribute stable peripheral resistance and sufficient placental blood supply under stimulated conditions. It is important to understand cardiovascular autonomic nervous system and haemodynamic control in normal pregnancy before being able to judge whether they are dysregulated in complicated pregnancies.