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Publisher: John Wiley and Sons   (Total: 1580 journals)

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Showing 1 - 200 of 1580 Journals sorted alphabetically
Abacus     Hybrid Journal   (Followers: 13, SJR: 0.48, h-index: 22)
About Campus     Hybrid Journal   (Followers: 5)
Academic Emergency Medicine     Hybrid Journal   (Followers: 65, SJR: 1.385, h-index: 91)
Accounting & Finance     Hybrid Journal   (Followers: 47, SJR: 0.547, h-index: 30)
ACEP NOW     Free   (Followers: 1)
Acta Anaesthesiologica Scandinavica     Hybrid Journal   (Followers: 52, SJR: 1.02, h-index: 88)
Acta Archaeologica     Hybrid Journal   (Followers: 158, SJR: 0.101, h-index: 9)
Acta Geologica Sinica (English Edition)     Hybrid Journal   (Followers: 3, SJR: 0.552, h-index: 41)
Acta Neurologica Scandinavica     Hybrid Journal   (Followers: 5, SJR: 1.203, h-index: 74)
Acta Obstetricia et Gynecologica Scandinavica     Hybrid Journal   (Followers: 15, SJR: 1.197, h-index: 81)
Acta Ophthalmologica     Hybrid Journal   (Followers: 6, SJR: 0.112, h-index: 1)
Acta Paediatrica     Hybrid Journal   (Followers: 56, SJR: 0.794, h-index: 88)
Acta Physiologica     Hybrid Journal   (Followers: 6, SJR: 1.69, h-index: 88)
Acta Polymerica     Hybrid Journal   (Followers: 9)
Acta Psychiatrica Scandinavica     Hybrid Journal   (Followers: 35, SJR: 2.518, h-index: 113)
Acta Zoologica     Hybrid Journal   (Followers: 6, SJR: 0.459, h-index: 29)
Acute Medicine & Surgery     Hybrid Journal   (Followers: 4)
Addiction     Hybrid Journal   (Followers: 35, SJR: 2.086, h-index: 143)
Addiction Biology     Hybrid Journal   (Followers: 13, SJR: 2.091, h-index: 57)
Adultspan J.     Hybrid Journal   (SJR: 0.127, h-index: 4)
Advanced Energy Materials     Hybrid Journal   (Followers: 27, SJR: 6.411, h-index: 86)
Advanced Engineering Materials     Hybrid Journal   (Followers: 26, SJR: 0.81, h-index: 81)
Advanced Functional Materials     Hybrid Journal   (Followers: 51, SJR: 5.21, h-index: 203)
Advanced Healthcare Materials     Hybrid Journal   (Followers: 14, SJR: 0.232, h-index: 7)
Advanced Materials     Hybrid Journal   (Followers: 268, SJR: 9.021, h-index: 345)
Advanced Materials Interfaces     Hybrid Journal   (Followers: 6, SJR: 1.177, h-index: 10)
Advanced Optical Materials     Hybrid Journal   (Followers: 7, SJR: 2.488, h-index: 21)
Advanced Science     Open Access   (Followers: 5)
Advanced Synthesis & Catalysis     Hybrid Journal   (Followers: 17, SJR: 2.729, h-index: 121)
Advances in Polymer Technology     Hybrid Journal   (Followers: 13, SJR: 0.344, h-index: 31)
Africa Confidential     Hybrid Journal   (Followers: 21)
Africa Research Bulletin: Economic, Financial and Technical Series     Hybrid Journal   (Followers: 13)
Africa Research Bulletin: Political, Social and Cultural Series     Hybrid Journal   (Followers: 10)
African Development Review     Hybrid Journal   (Followers: 33, SJR: 0.275, h-index: 17)
African J. of Ecology     Hybrid Journal   (Followers: 15, SJR: 0.477, h-index: 39)
Aggressive Behavior     Hybrid Journal   (Followers: 15, SJR: 1.391, h-index: 66)
Aging Cell     Open Access   (Followers: 11, SJR: 4.374, h-index: 95)
Agribusiness : an Intl. J.     Hybrid Journal   (Followers: 6, SJR: 0.627, h-index: 14)
Agricultural and Forest Entomology     Hybrid Journal   (Followers: 16, SJR: 0.925, h-index: 43)
Agricultural Economics     Hybrid Journal   (Followers: 45, SJR: 1.099, h-index: 51)
AIChE J.     Hybrid Journal   (Followers: 31, SJR: 1.122, h-index: 120)
Alcoholism and Drug Abuse Weekly     Hybrid Journal   (Followers: 7)
Alcoholism Clinical and Experimental Research     Hybrid Journal   (Followers: 7, SJR: 1.416, h-index: 125)
Alimentary Pharmacology & Therapeutics     Hybrid Journal   (Followers: 33, SJR: 2.833, h-index: 138)
Alimentary Pharmacology & Therapeutics Symposium Series     Hybrid Journal   (Followers: 3)
Allergy     Hybrid Journal   (Followers: 51, SJR: 3.048, h-index: 129)
Alternatives to the High Cost of Litigation     Hybrid Journal   (Followers: 3)
American Anthropologist     Hybrid Journal   (Followers: 145, SJR: 0.951, h-index: 61)
American Business Law J.     Hybrid Journal   (Followers: 24, SJR: 0.205, h-index: 17)
American Ethnologist     Hybrid Journal   (Followers: 90, SJR: 2.325, h-index: 51)
American J. of Economics and Sociology     Hybrid Journal   (Followers: 28, SJR: 0.211, h-index: 26)
American J. of Hematology     Hybrid Journal   (Followers: 33, SJR: 1.761, h-index: 77)
American J. of Human Biology     Hybrid Journal   (Followers: 12, SJR: 1.018, h-index: 58)
American J. of Industrial Medicine     Hybrid Journal   (Followers: 16, SJR: 0.993, h-index: 85)
American J. of Medical Genetics Part A     Hybrid Journal   (Followers: 16, SJR: 1.115, h-index: 61)
American J. of Medical Genetics Part B: Neuropsychiatric Genetics     Hybrid Journal   (Followers: 4, SJR: 1.771, h-index: 107)
American J. of Medical Genetics Part C: Seminars in Medical Genetics     Partially Free   (Followers: 6, SJR: 2.315, h-index: 79)
American J. of Physical Anthropology     Hybrid Journal   (Followers: 37, SJR: 1.41, h-index: 88)
American J. of Political Science     Hybrid Journal   (Followers: 272, SJR: 5.101, h-index: 114)
American J. of Primatology     Hybrid Journal   (Followers: 15, SJR: 1.197, h-index: 63)
American J. of Reproductive Immunology     Hybrid Journal   (Followers: 3, SJR: 1.347, h-index: 75)
American J. of Transplantation     Hybrid Journal   (Followers: 17, SJR: 2.792, h-index: 140)
American J. on Addictions     Hybrid Journal   (Followers: 9, SJR: 0.843, h-index: 57)
Anaesthesia     Hybrid Journal   (Followers: 136, SJR: 1.404, h-index: 88)
Analyses of Social Issues and Public Policy     Hybrid Journal   (Followers: 10, SJR: 0.397, h-index: 18)
Analytic Philosophy     Hybrid Journal   (Followers: 18)
Anatomia, Histologia, Embryologia: J. of Veterinary Medicine Series C     Hybrid Journal   (Followers: 3, SJR: 0.295, h-index: 27)
Anatomical Sciences Education     Hybrid Journal   (Followers: 1, SJR: 0.633, h-index: 24)
Andrologia     Hybrid Journal   (Followers: 2, SJR: 0.528, h-index: 45)
Andrology     Hybrid Journal   (Followers: 2, SJR: 0.979, h-index: 14)
Angewandte Chemie     Hybrid Journal   (Followers: 196)
Angewandte Chemie Intl. Edition     Hybrid Journal   (Followers: 219, SJR: 6.229, h-index: 397)
Animal Conservation     Hybrid Journal   (Followers: 39, SJR: 1.576, h-index: 62)
Animal Genetics     Hybrid Journal   (Followers: 8, SJR: 0.957, h-index: 67)
Animal Science J.     Hybrid Journal   (Followers: 6, SJR: 0.569, h-index: 24)
Annalen der Physik     Hybrid Journal   (Followers: 5, SJR: 1.46, h-index: 40)
Annals of Anthropological Practice     Partially Free   (Followers: 2, SJR: 0.187, h-index: 5)
Annals of Applied Biology     Hybrid Journal   (Followers: 7, SJR: 0.816, h-index: 56)
Annals of Clinical and Translational Neurology     Open Access   (Followers: 1)
Annals of Human Genetics     Hybrid Journal   (Followers: 9, SJR: 1.191, h-index: 67)
Annals of Neurology     Hybrid Journal   (Followers: 47, SJR: 5.584, h-index: 241)
Annals of Noninvasive Electrocardiology     Hybrid Journal   (Followers: 2, SJR: 0.531, h-index: 38)
Annals of Public and Cooperative Economics     Hybrid Journal   (Followers: 9, SJR: 0.336, h-index: 23)
Annals of the New York Academy of Sciences     Hybrid Journal   (Followers: 5, SJR: 2.389, h-index: 189)
Annual Bulletin of Historical Literature     Hybrid Journal   (Followers: 13)
Annual Review of Information Science and Technology     Hybrid Journal   (Followers: 14)
Anthropology & Education Quarterly     Hybrid Journal   (Followers: 25, SJR: 0.72, h-index: 31)
Anthropology & Humanism     Hybrid Journal   (Followers: 17, SJR: 0.137, h-index: 3)
Anthropology News     Hybrid Journal   (Followers: 15)
Anthropology of Consciousness     Hybrid Journal   (Followers: 11, SJR: 0.172, h-index: 5)
Anthropology of Work Review     Hybrid Journal   (Followers: 11, SJR: 0.256, h-index: 5)
Anthropology Today     Hybrid Journal   (Followers: 90, SJR: 0.545, h-index: 15)
Antipode     Hybrid Journal   (Followers: 49, SJR: 2.212, h-index: 69)
Anz J. of Surgery     Hybrid Journal   (Followers: 7, SJR: 0.432, h-index: 59)
Anzeiger für Schädlingskunde     Hybrid Journal   (Followers: 1)
Apmis     Hybrid Journal   (Followers: 1, SJR: 0.855, h-index: 73)
Applied Cognitive Psychology     Hybrid Journal   (Followers: 70, SJR: 0.754, h-index: 69)
Applied Organometallic Chemistry     Hybrid Journal   (Followers: 7, SJR: 0.632, h-index: 58)
Applied Psychology     Hybrid Journal   (Followers: 206, SJR: 1.023, h-index: 64)
Applied Psychology: Health and Well-Being     Hybrid Journal   (Followers: 49, SJR: 0.868, h-index: 13)
Applied Stochastic Models in Business and Industry     Hybrid Journal   (Followers: 5, SJR: 0.613, h-index: 24)
Aquaculture Nutrition     Hybrid Journal   (Followers: 14, SJR: 1.025, h-index: 55)
Aquaculture Research     Hybrid Journal   (Followers: 31, SJR: 0.807, h-index: 60)
Aquatic Conservation Marine and Freshwater Ecosystems     Hybrid Journal   (Followers: 36, SJR: 1.047, h-index: 57)
Arabian Archaeology and Epigraphy     Hybrid Journal   (Followers: 11, SJR: 0.453, h-index: 11)
Archaeological Prospection     Hybrid Journal   (Followers: 12, SJR: 0.922, h-index: 21)
Archaeology in Oceania     Hybrid Journal   (Followers: 13, SJR: 0.745, h-index: 18)
Archaeometry     Hybrid Journal   (Followers: 27, SJR: 0.809, h-index: 48)
Archeological Papers of The American Anthropological Association     Hybrid Journal   (Followers: 15, SJR: 0.156, h-index: 2)
Architectural Design     Hybrid Journal   (Followers: 25, SJR: 0.261, h-index: 9)
Archiv der Pharmazie     Hybrid Journal   (Followers: 4, SJR: 0.628, h-index: 43)
Archives of Drug Information     Hybrid Journal   (Followers: 5)
Archives of Insect Biochemistry and Physiology     Hybrid Journal   (SJR: 0.768, h-index: 54)
Area     Hybrid Journal   (Followers: 12, SJR: 0.938, h-index: 57)
Art History     Hybrid Journal   (Followers: 246, SJR: 0.153, h-index: 13)
Arthritis & Rheumatology     Hybrid Journal   (Followers: 50, SJR: 1.984, h-index: 20)
Arthritis Care & Research     Hybrid Journal   (Followers: 26, SJR: 2.256, h-index: 114)
Artificial Organs     Hybrid Journal   (Followers: 1, SJR: 0.872, h-index: 60)
ASHE Higher Education Reports     Hybrid Journal   (Followers: 15)
Asia & the Pacific Policy Studies     Open Access   (Followers: 16)
Asia Pacific J. of Human Resources     Hybrid Journal   (Followers: 323, SJR: 0.494, h-index: 19)
Asia Pacific Viewpoint     Hybrid Journal   (Followers: 1, SJR: 0.616, h-index: 26)
Asia-Pacific J. of Chemical Engineering     Hybrid Journal   (Followers: 8, SJR: 0.345, h-index: 20)
Asia-pacific J. of Clinical Oncology     Hybrid Journal   (Followers: 6, SJR: 0.554, h-index: 14)
Asia-Pacific J. of Financial Studies     Hybrid Journal   (SJR: 0.241, h-index: 7)
Asia-Pacific Psychiatry     Hybrid Journal   (Followers: 4, SJR: 0.377, h-index: 7)
Asian Economic J.     Hybrid Journal   (Followers: 8, SJR: 0.234, h-index: 21)
Asian Economic Policy Review     Hybrid Journal   (Followers: 4, SJR: 0.196, h-index: 12)
Asian J. of Control     Hybrid Journal   (SJR: 0.862, h-index: 34)
Asian J. of Endoscopic Surgery     Hybrid Journal   (SJR: 0.394, h-index: 7)
Asian J. of Organic Chemistry     Hybrid Journal   (Followers: 6, SJR: 1.443, h-index: 19)
Asian J. of Social Psychology     Hybrid Journal   (Followers: 5, SJR: 0.665, h-index: 37)
Asian Politics and Policy     Hybrid Journal   (Followers: 12, SJR: 0.207, h-index: 7)
Asian Social Work and Policy Review     Hybrid Journal   (Followers: 5, SJR: 0.318, h-index: 5)
Asian-pacific Economic Literature     Hybrid Journal   (Followers: 5, SJR: 0.168, h-index: 15)
Assessment Update     Hybrid Journal   (Followers: 4)
Astronomische Nachrichten     Hybrid Journal   (Followers: 2, SJR: 0.701, h-index: 40)
Atmospheric Science Letters     Open Access   (Followers: 29, SJR: 1.332, h-index: 27)
Austral Ecology     Hybrid Journal   (Followers: 15, SJR: 1.095, h-index: 66)
Austral Entomology     Hybrid Journal   (Followers: 9, SJR: 0.524, h-index: 28)
Australasian J. of Dermatology     Hybrid Journal   (Followers: 8, SJR: 0.714, h-index: 40)
Australasian J. On Ageing     Hybrid Journal   (Followers: 6, SJR: 0.39, h-index: 22)
Australian & New Zealand J. of Statistics     Hybrid Journal   (Followers: 14, SJR: 0.275, h-index: 28)
Australian Accounting Review     Hybrid Journal   (Followers: 4, SJR: 0.709, h-index: 14)
Australian and New Zealand J. of Family Therapy (ANZJFT)     Hybrid Journal   (Followers: 3, SJR: 0.382, h-index: 12)
Australian and New Zealand J. of Obstetrics and Gynaecology     Hybrid Journal   (Followers: 47, SJR: 0.814, h-index: 49)
Australian and New Zealand J. of Public Health     Hybrid Journal   (Followers: 11, SJR: 0.82, h-index: 62)
Australian Dental J.     Hybrid Journal   (Followers: 7, SJR: 0.482, h-index: 46)
Australian Economic History Review     Hybrid Journal   (Followers: 4, SJR: 0.171, h-index: 12)
Australian Economic Papers     Hybrid Journal   (Followers: 29, SJR: 0.23, h-index: 9)
Australian Economic Review     Hybrid Journal   (Followers: 6, SJR: 0.357, h-index: 21)
Australian Endodontic J.     Hybrid Journal   (Followers: 3, SJR: 0.513, h-index: 24)
Australian J. of Agricultural and Resource Economics     Hybrid Journal   (Followers: 3, SJR: 0.765, h-index: 36)
Australian J. of Grape and Wine Research     Hybrid Journal   (Followers: 5, SJR: 0.879, h-index: 56)
Australian J. of Politics & History     Hybrid Journal   (Followers: 14, SJR: 0.203, h-index: 14)
Australian J. of Psychology     Hybrid Journal   (Followers: 18, SJR: 0.384, h-index: 30)
Australian J. of Public Administration     Hybrid Journal   (Followers: 408, SJR: 0.418, h-index: 29)
Australian J. of Rural Health     Hybrid Journal   (Followers: 5, SJR: 0.43, h-index: 34)
Australian Occupational Therapy J.     Hybrid Journal   (Followers: 72, SJR: 0.59, h-index: 29)
Australian Psychologist     Hybrid Journal   (Followers: 12, SJR: 0.331, h-index: 31)
Australian Veterinary J.     Hybrid Journal   (Followers: 20, SJR: 0.459, h-index: 45)
Autism Research     Hybrid Journal   (Followers: 35, SJR: 2.126, h-index: 39)
Autonomic & Autacoid Pharmacology     Hybrid Journal   (SJR: 0.371, h-index: 29)
Banks in Insurance Report     Hybrid Journal   (Followers: 1)
Basic & Clinical Pharmacology & Toxicology     Hybrid Journal   (Followers: 11, SJR: 0.539, h-index: 70)
Basic and Applied Pathology     Open Access   (Followers: 2, SJR: 0.113, h-index: 4)
Basin Research     Hybrid Journal   (Followers: 5, SJR: 1.54, h-index: 60)
Bauphysik     Hybrid Journal   (Followers: 2, SJR: 0.194, h-index: 5)
Bauregelliste A, Bauregelliste B Und Liste C     Hybrid Journal  
Bautechnik     Hybrid Journal   (Followers: 1, SJR: 0.321, h-index: 11)
Behavioral Interventions     Hybrid Journal   (Followers: 9, SJR: 0.297, h-index: 23)
Behavioral Sciences & the Law     Hybrid Journal   (Followers: 24, SJR: 0.736, h-index: 57)
Berichte Zur Wissenschaftsgeschichte     Hybrid Journal   (Followers: 9, SJR: 0.11, h-index: 5)
Beton- und Stahlbetonbau     Hybrid Journal   (Followers: 2, SJR: 0.493, h-index: 14)
Biochemistry and Molecular Biology Education     Hybrid Journal   (Followers: 6, SJR: 0.311, h-index: 26)
Bioelectromagnetics     Hybrid Journal   (Followers: 1, SJR: 0.568, h-index: 64)
Bioengineering & Translational Medicine     Open Access  
BioEssays     Hybrid Journal   (Followers: 10, SJR: 3.104, h-index: 155)
Bioethics     Hybrid Journal   (Followers: 14, SJR: 0.686, h-index: 39)
Biofuels, Bioproducts and Biorefining     Hybrid Journal   (Followers: 1, SJR: 1.725, h-index: 56)
Biological J. of the Linnean Society     Hybrid Journal   (Followers: 16, SJR: 1.172, h-index: 90)
Biological Reviews     Hybrid Journal   (Followers: 4, SJR: 6.469, h-index: 114)
Biologie in Unserer Zeit (Biuz)     Hybrid Journal   (Followers: 42, SJR: 0.12, h-index: 1)
Biology of the Cell     Full-text available via subscription   (Followers: 9, SJR: 1.812, h-index: 69)
Biomedical Chromatography     Hybrid Journal   (Followers: 6, SJR: 0.572, h-index: 49)
Biometrical J.     Hybrid Journal   (Followers: 5, SJR: 0.784, h-index: 44)
Biometrics     Hybrid Journal   (Followers: 36, SJR: 1.906, h-index: 96)
Biopharmaceutics and Drug Disposition     Hybrid Journal   (Followers: 10, SJR: 0.715, h-index: 44)
Biopolymers     Hybrid Journal   (Followers: 18, SJR: 1.199, h-index: 104)
Biotechnology and Applied Biochemistry     Hybrid Journal   (Followers: 45, SJR: 0.415, h-index: 55)
Biotechnology and Bioengineering     Hybrid Journal   (Followers: 160, SJR: 1.633, h-index: 146)
Biotechnology J.     Hybrid Journal   (Followers: 14, SJR: 1.185, h-index: 51)
Biotechnology Progress     Hybrid Journal   (Followers: 39, SJR: 0.736, h-index: 101)
Biotropica     Hybrid Journal   (Followers: 20, SJR: 1.374, h-index: 71)
Bipolar Disorders     Hybrid Journal   (Followers: 9, SJR: 2.592, h-index: 100)
Birth     Hybrid Journal   (Followers: 38, SJR: 0.763, h-index: 64)
Birth Defects Research Part A : Clinical and Molecular Teratology     Hybrid Journal   (Followers: 2, SJR: 0.727, h-index: 77)
Birth Defects Research Part B: Developmental and Reproductive Toxicology     Hybrid Journal   (Followers: 6, SJR: 0.468, h-index: 47)
Birth Defects Research Part C : Embryo Today : Reviews     Hybrid Journal   (SJR: 1.513, h-index: 55)
BJOG : An Intl. J. of Obstetrics and Gynaecology     Partially Free   (Followers: 243, SJR: 2.083, h-index: 125)

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Journal Cover Acta Obstetricia et Gynecologica Scandinavica
  [SJR: 1.197]   [H-I: 81]   [15 followers]  Follow
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0001-6349 - ISSN (Online) 1600-0412
   Published by John Wiley and Sons Homepage  [1580 journals]
  • Cervical HPV prevalence and genotype distribution in immunosuppressed
           Danish women
    • Abstract: IntroductionWomen receiving immunosuppressive treatment due to organ transplantation are at increased risk of Human papilloma virus (HPV)‐related diseases, including cervical neoplasia. This pilot study aimed to describe the cervical HPV prevalence and genotype distribution in immunosuppressed Danish women.Material and MethodsWe included women who underwent renal‐ (RTR) or bone marrow transplantation (BMTR) in 2009‐2012 or 2014 at Aarhus University Hospital, Denmark. Women undergoing transplantation in 2009‐2012 had one cervical cytology performed, whereas women undergoing transplantation in 2014 had three cervical cytologies performed; one before and two after transplantation. The samples were examined for cytological abnormalities and tested for HPV using Cobas® HPV Test and CLART® HPV2 Test.ResultsOf 94 eligible cases we included 60 RTR and BMTR. The overall prevalence of high‐risk HPV was 15.0 (95% CI; 7.1–26.6) and the prevalence was higher among BMTR (29.4, CI; 10.3–56.0) than in RTR (9.3%, CI; 2.6–22.1) although this was not statistically significant (p=0.10). The distribution of high‐risk HPV was broad with HPV 45 as the most common genotype (3.3%). The prevalences of high‐risk HPV types included in the bivalent/quadrivalent and the nonavalent vaccines were 1.7% and 8.3%, respectively. The prevalence of low‐grade and high‐grade cytological abnormalities was 6.7% and 5.0%, respectively.ConclusionsImmunosuppressed women were infected with a broad range of high‐risk HPV genotypes and the prevalence of cytological abnormalities was higher than found in previous studies of the general population. The nonavalent HPV vaccine will offer immunosuppressed individuals a greater protection against HPV‐related diseases compared to the bivalent/quadrivalent HPV vaccines.This article is protected by copyright. All rights reserved.
  • Decreasing trends in number of depot medroxyprogesterone acetate starters
           in Norway – a cross‐sectional study
    • Abstract: IntroductionIn this study, we examined changes in depot medroxyprogesterone acetate (DMPA) prescriptions over a time‐period when new professions started prescribing, and when the method gained some negative media attention.Material and methodsThe Norwegian Prescription Database provided data on hormonal contraception from 2006 through 2012. We estimated annual number of DMPA users by calculating doses sold per day/1000 women and calculated, for each contraceptive method on annual basis, a proportion of defined daily doses of all hormonal contraceptives in 5‐year age groups at reproductive age. All analyses were done in SPSS, version 22, with chi‐square test, t‐test, and survival analysis with p < 0.05 as significance level.ResultsThere were minor differences in overall DMPA use during the study years. The take‐out rate was equivalent to 11–12 per 1000 women aged 15–49 years. DMPA sales amounted to nearly 4% of all daily doses of hormonal contraceptives sold. General practitioners and physicians without a specialty were the major prescribers. The number of starters decreased by nearly 40% during the study years and was consistent across age groups. The average use duration among starters was 17.7 (95% CI: 17.5–17.9) months (range 0–90). There were minor changes in the relative proportion of long‐term users beyond 24 months during the study years.ConclusionsDMPA plays a minor role in the overall use of hormonal contraception in Norway, even among teenagers. The number of starters is decreasing, indicating a more restrictive attitude toward first use, especially among general practitioners.This article is protected by copyright. All rights reserved.
  • Long‐term evaluation of painful symptoms and fertility after surgery for
           large rectovaginal endometriosis nodule: a retrospective study
    • Abstract: Optimal surgical treatment of rectovaginal endometriosis remains a controversial topic. The objective of this study was to evaluate long term postoperative outcomes after rectal shaving or colorectal resection for rectovaginal endometriosisMaterial and methods195 patients underwent surgery (172 managed by shaving, 23 by colorectal resection) between January 2000 and June 2013 for rectovaginal endometriosis (>2cm) involving at least the serosa of the rectum. Primary outcome measures were pain and fertility. Secondary outcome measures were complications, recurrence rates and quality of lifeResultsMean follow‐up was 60±42 months in the shaving group and 67±47 months in the resection group. The mean VAS score for pelvic pain between the pre and postoperative period decreased from 5.5±3.5 (shaving group) and 7.3±2.9 (resection group) to 2.3±2.4 (p
  • Diagnostic accuracy of magnetic resonance imaging in detecting the
           severity of abnormal invasive placenta: a systematic review and
    • Abstract: IntroductionAccurate prenatal diagnosis of abnormally invasive placenta (AIP) is fundamental because it significantly reduces maternal morbiditiesMaterial and MethodsMedline, Embase, CINAHL and The Cochrane databases were searched. The primary aim of the present review was to elucidate the diagnostic accuracy of prenatal magnetic resonance imaging (MRI) in recognizing the severity of AIP, defined as the depth and topography of invasion. The secondary aim was to ascertain the strength of association between each MRI sign and the depth of placental invasion and to test their individual predictive accuracy in detecting such invasion. Inclusion criteria were studies on women who had prenatal MRI for ultrasound suspicion or the presence of clinical risk factors for AIP. Estimates of sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratio were calculated using the hierarchical summary receiver characteristics curve model, while individual data random‐effect logistic regression, was used to calculate ORResultsTwenty studies (1080 pregnancies undergoing MRI mainly for the ultrasound suspicion of AIP) were included. MRI showed a sensitivity of 94.4% (95% CI 15.8‐99.9), 100% (95% CI 75.3‐100) and 86.5% (95% CI 74.2‐94.4) for detection of placenta accreta, increta, and percreta; the corresponding for specificity were 98.8% (95% CI 70.7‐100), 97.3% (95% CI 93.3‐99.3), 96.8% (95% CI 93.5‐98.7). MRI identified 100% of cases with S1 and 100% of those with S2 invasion confirmed at surgery. Among the different MRI signs, intra‐placental dark bands showed the best sensitivity for the detection of placenta accreta, increta and percreta respectively, as well as abnormal intra‐placental vascularity, uterine bulging was associated with a higher risk of increta and percreta, exophitic mass and bladder tenting with placenta percretaConclusionPrenatal MRI has an excellent diagnostic accuracy in identifying the depth and the topography of placental invasion. However, these findings come mainly from studies in which MRI was performed as a secondary imaging tool in women already screened for AIP on ultrasound and might not reflect its actual diagnostic performance in detecting the severity of these disorders.This article is protected by copyright. All rights reserved.
  • Placental development and function in women with a history of
           placenta‐related complications: a systematic review
    • Abstract: IntroductionWomen with a history of placenta‐related pregnancy complications, such as preeclampsia, intra‐uterine growth restriction or preterm delivery, have an increased risk for recurrence of such complications. This recurrence is likely the result of underlying endothelial dysfunction that leads to abnormal placentation, especially in complications with an early onset. This study provides an overview of biomarkers of placental development and function in pregnancies from women with a history of pregnancy‐related complications.Material and methodsA systematic literature search was conducted limited to human studies and including keywords related to a history of placenta‐related complications and markers of placental development and function. Two independent reviewers assessed eligibility and quality of 1,553 retrieved unique articles.ResultsFive articles reporting on placental development and function in women with an obstetric history of preeclampsia (n=3), intra‐uterine growth restriction (n=1) and preterm delivery (n=2) were eligible for quality assessment. We identified associations between a history of preeclampsia and abnormal placental histological findings at term in the current pregnancy, but found contradicting results regarding presence of uterine artery notching. In women with a history of very preterm delivery (
  • Very tight versus tight control: which should be the criteria for
           pharmacologic therapy dose adjustment in diabetes in pregnancy'
           Evidence from randomized controlled trials
    • Abstract: IntroductionThere is inconclusive evidence from randomized controlled trials (RCTs) to support any specific criteria for pharmacologic therapy dose adjustment in diabetes in pregnancy. Our objective was to analyze the criteria for dose adjustment of pharmacologic treatment for diabetes mellitus (DM) in pregnancy.Material and methodsData sources: MEDLINE, OVID and Cochrane Library were searched from their inception to September 2017. Selection criteria included all trials of DM in pregnancy managed by oral hypoglycemic agents or insulin reporting criteria for pharmacologic therapy dose adjustment. RCTs in women with pregestational DM and gestational DM (GDM) were included. For each trial, data regarding glucose values used for pharmacologic therapy dose adjustment were extracted and carefully reviewed.ResultsOf 51 RCTs on therapy for GDM or pregestational DM, 17 (4,230 women) were included as they reported criteria for pharmacologic therapy dose adjustment. Most of them (88%, 15/17) included women with GDM only. For RCTs including women with GDM, 12/16 (75%) used the two step approach; 3 (19%) used the one step approach; 1 (6%) used either the one or two step approach. Regarding the type of initial therapy, 13 (77%) RCTs used different types and doses of insulin; 9 (53%) used metformin; 5 (30%) used glyburide; and 1 (6%) used placebo. In most RCTs glucose monitoring was assessed four times daily, i.e. fasting (all RCTs) and 2 hours (15 RCTs, 88%) after each of the three main meals – breakfast, lunch, and dinner. For fasting glucose target, all used a value 50%, 1 (6%) used >30%, and 1 (6%) used >20% of the values higher than the target value; while 1 (6%) used appearance of glycosuria.ConclusionsWhen evaluating RCTs which included criteria for pharmacologic GDM therapy dose adjustment, the most common criteria for diagnosis was the two step test, and the most common used therapies were insulin and metformin. Regarding glucose monitoring, the most common frequency was four times per day, fasting and 2 hours after each main meal, using as target glucose values 95mg/dL and 120mg/dL, respectively. Importantly, we found six different criteria for pharmacologic GDM therapy dose adjustment, with the majority using very tight criteria of either 1 or 2 values per week higher than the target values, of which two thirds used only 1 value, and one third 2 values.This article is protected by copyright. All rights reserved.
  • Are women positive for the One Step but negative for the Two Step
           screening tests for gestational diabetes at higher risk for adverse
    • Abstract: IntroductionTo evaluate if women meeting criteria for gestational diabetes mellitus (GDM) by the One Step test as per International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria but not by other less strict criteria have adverse pregnancy outcomes compared to GDM negative controls. The primary outcome was the incidence of macrosomia, defined as birth weight >4,000 grams.Material and methodsElectronic databases were searched from their inception until May 2017. All studies identifying pregnant women negative at the Two Step test, but positive at the One Step test for IADPSG criteria. We excluded studies that randomized women to the One Step versus the Two Step tests; studies that compared different criteria within the same screening method; randomized studies comparing treatments for GDM; and studies comparing incidence of GDM in women doing the One Step test versus the Two Step test.ResultsEight retrospective cohort studies, including 29,983 women, were included. 5 study groups and 4 control groups were identified. The heterogeneity between the studies was high. Gestational hypertension, preeclampsia, and large for gestational age, as well as in some analyses cesarean delivery, macrosomia and preterm birth, were significantly more frequent, and small for gestational age in some analyses significantly less frequent, in women GDM positive by the One Step, but not the Two Step.ConclusionWomen meeting criteria for GDM by IADPSG criteria but not by other less strict criteria have an increased risk of adverse pregnancy outcomes such as gestational hypertension, preeclampsia, and large for gestational age, compared to GDM negative controls. Based on these findings, and evidence from other studies that treatment decrease these adverse outcomes, we suggest screening for GDM using the IADPSG criteria.This article is protected by copyright. All rights reserved.
  • Risk of bowel obstruction during IVF treatment of patients with deep
           infiltrating endometriosis
    • Abstract: IntroductionWomen with endometriosis often experience pain and infertility. Medical treatment interferes with the possibility to attain pregnancy. For infertile women with endometriosis surgery is a possible treatment, but with advanced disease there is an increased risk of serious complications. With only limited pain, the women will often be referred for in vitro fertilization (IVF) treatment instead. The disease is estrogen dependant and during IVF treatment the women could theoretically experience worsening of their symptoms.Material and methodsThe study is a retrospective cohort study of 76 women with bowel endometriosis treated conservatively and having IVF treatment.ResultsNine (11,8%) of the women experienced severe worsening of their bowel related symptoms, including two patients presenting with colon ileus. One additional woman had no previous diagnosis of endometriosis before she presented with subocclusion of the bowel during IVF. In all cases the IVF treatment was stopped.ConclusionsOur study revealed that bowel endometriosis increases the risk of complications during IVF treatment. This is in contrast to several publications. However, our study population is different due to the fact that none of these women had previous operation for bowel endometriosis. In 88% of the cases the women completed fertility treatment without need for surgery.This article is protected by copyright. All rights reserved.
  • Gut microbiome in gestational diabetes: A Cross‐sectional study of
           mothers and offspring 5 years post‐partum
    • Abstract: IntroductionAn altered gut microbiome composition is shown to be associated with various diseases and health outcomes. We compare the gut microbiota of women who developed gestational diabetes mellitus (GDM) to those who did not, and the gut microbiota of their offspring, to determine any differences in the composition and diversity of their gut microbiota, which may be correlated with their GDM state.Material and methodsAll women were at high risk for GDM and participated in the Finnish Gestational Diabetes Prevention Study (RADIEL). Stool samples were obtained, 5 years post‐partum, from 60 GDM positive women, 68 non‐GDM control women, and their children (n=109), 237 individuals in total. 16S ribosomal RNA gene sequencing was employed to determine the composition of bacterial communities present. Statistical correlations were inferred between clinical variables and microbiota, whilst taking into account potential confounders.ResultsIn mothers, no significant differences were observed in microbiota composition between the two groups. Genus Anaerotruncus was increased in children of GDM women (p
  • Reproducibility and acceptability of ultrasound measurements of
           head‐perineum distance
    • Abstract: IntroductionWe aimed to test reproducibility of head‐perineum distance (HPD) measurements using two different ultrasound devices and five examiners, to compare ultrasound measurements and clinical assessments and to study if ultrasound examinations were acceptable for women in labor.Material and methodsA reproducibility study was performed at Lund University Hospital, Sweden and Landspitali University Hospital, Iceland from February 2015 to February 2017. The study population comprised 40 healthy women in labor. HPD was measured with three replicate measurements from each woman with two different ultrasound devices, and the measurements were compared with clinical assessments. Acceptability was tested with visual analog scale (VAS), and the mean VAS score from both ultrasound devices was compared with the VAS score from clinical palpation.ResultsThe median time interval between start of examinations with devices was 10 minutes (range 1‐26 minutes). The intra‐observer repeatability coefficient was 4.3 mm and the intraclass correlation coefficient was 0.97 (95% CI 0.95‐0.98). The intraclass correlation coefficient between the two devices was 0.86 (95% CI 0.74‐0.93) and limits of agreement were ‐9.6 mm to 16.6 mm. However, we observed a significant mean HPD difference between devices (3.5mm; 95%CI 1.4‐5.6mm). Clinical assessments and the mean measurements of HPD were correlated (r=0.64, p
  • Understanding the associations and significance of fetal movements in
           overweight or obese pregnant women: a systematic review
    • Abstract: IntroductionPresentation with decreased fetal movement (DFM) is associated with fetal growth restriction and stillbirth. Some studies report DFM is frequent amongst overweight or obese mothers. We aimed to determine the significance and associations of fetal movements in women of increased body size.Materials and MethodsThis systematic review was conducted in accordance with the PRISMA statement and the protocol was registered with PROSPERO (CRD42016046352). Major databases were explored from inception to September 2017, using a pre‐defined search strategy. We restricted inclusion to studies published in English and considered studies of any design that compared fetal movements in women of increased and normal body size. Two authors independently extracted data and assessed quality.ResultsWe included 23 publications from 19 observational studies; data were extracted from 10 studies. Increased maternal body size was not associated with altered perception of fetal movement (4 studies, 95 women, very low‐quality evidence), but was associated with increased presentation for DFM (2 cohort studies, 20,588 women, OR 1.56, 95% CI 1.27‐1.92: 3 case‐control studies, 3,445 women, OR 1.32, 95% CI 1.12‐1.54; low quality evidence). Amongst women with DFM, increased maternal body size was associated with increased risk of stillbirth and fetal growth restriction (1 study, 2,168 women, very low‐quality evidence).ConclusionsThis systematic review identified limited evidence that women with increased body size are more likely to present with DFM but do not have impaired perception of fetal movements. In women with DFM, increased body size is associated with worse pregnancy outcome, including stillbirth.This article is protected by copyright. All rights reserved.
  • Small fetal thymus and adverse obstetrical outcome: a systematic review
           and a meta‐analysis
    • Abstract: IntroductionTo explore the association between small fetal thymus on ultrasound and adverse obstetrical outcome.Material and methodsMedline, Embase, Cochrane and Web of Science databases were searched. Primary outcome was the risk of preterm birth before 37 and 34 weeks in fetuses with compared to those without a small thymus on ultrasound. Secondary outcomes: occurrence of chorioamnionitis, intra‐uterine growth restriction, neonatal sepsis, gestational age at birth, birthweight, neonatal morbidity and pre‐eclampsia.ResultsTwelve studies including 1744 fetuses who had ultrasound assessment of thymus during pregnancy were included. Women with preterm premature rupture of the membranes (PPROM) or with preterm labour with a small fetal thymus were at higher risk of preterm birth
  • Pregnancy prior to recurrent pregnancy loss more often complicated by
           post‐term birth and perinatal death
    • Abstract: IntroductionThe cause of recurrent pregnancy loss remains often unknown. Possibly, pathophysiological pathways are shared with other pregnancy complications.Material and methodsAll women with secondary recurrent pregnancy loss (SRPL) visiting Leiden University Medical Centre (January 2000‐2015) were included in this retrospective cohort to assess whether women with SRPL have a more complicated first pregnancy compared to control women. SRPL was defined as ≥ 3 consecutive pregnancy losses before 22 weeks’ gestation, with a previous birth. The control group consisted of all Dutch nullipara delivering a singleton (January 2000‐2015). Information was obtained from the Dutch Perinatal Registry. Outcomes were preeclampsia, preterm birth, post‐term birth, intrauterine growth restriction, breach position, induction of labor, Caesarean section, congenital abnormalities, perinatal death and severe hemorrhage in the first ongoing pregnancy. Subgroup analyses were performed for women with idiopathic SRPL and for women ≤ 35 years.Results172 women with SRPL and 1.196.178 control women were included. Women with SRPL were older and had a higher body mass index; 29.7 years versus 28.8 years and 25.1 versus 24.1, respectively. Women with SRPL more often had a post‐term birth (OR 1.86 95%CI (1.10‐3.17)) and more perinatal deaths occurred in women with SRPL compared to the control group (OR 5.03 95%CI (2.48‐10.2)). Similar results were found in both subgroup analyses.ConclusionsThe first ongoing pregnancy of women with (idiopathic) SRPL is more often complicated by post‐term birth and perinatal death. Revealing possible links between SRPL and these pregnancy complications might lead to a better understanding of underlying pathophysiology.This article is protected by copyright. All rights reserved.
  • Racial disparities in comorbidity and severe maternal morbidity/mortality
           in the United States: an analysis of temporal trends
    • Abstract: IntroductionSevere maternal morbidity and mortality have increased in the USA in recent years. This trend has not been consistent across all racial groups. The reasons behind this, and the relationship between pre‐existing conditions, pregnancy‐associated disease and Severe maternal morbidity/mortality, have not been fully explored.Material and methodsAnnual data on delivery hospitalizations between 1993‐2012 were obtained from the Nationwide Inpatient Sample (NIS), representing a 20% sample of hospital discharges from across the USA. Chi square tests for trend were used to examine temporal patterns in the proportion of pregnancies affected by comorbidities as defined by the Obstetric Comorbidity Score and were stratified by maternal race. Logistic regression was used to determine the impact of temporal increases in comorbidity on Severe maternal morbidity/mortality.ResultsIn 1993, 34.3% of pregnancies had a comorbidity score of ≥1; this significantly increased to 44.1% by 2012 (p
  • Returning to work after laparoscopic myomectomy: a prospective
           observational study
    • Abstract: IntroductionLaparoscopic myomectomy offers women many benefits over conventional open surgery, including an expedited recovery and return to employment. Our study evaluates the time taken for women to return to work after laparoscopic myomectomy and identifies factors prolonging recovery to over eight weeks.Material and methodsWe prospectively evaluated 94 women undergoing laparoscopic myomectomy by a single surgeon between January 2012 and March 2015. Women had standardised pre‐operative counseling and completed a validated return to work questionnaire three months post‐operatively via telephone, post or in clinic.Results71/94 (75.5%) women completed the questionnaire. Results were analysed comparing women who returned to work in eight weeks or less (43/71 (60.6%)) to those who returned over eight weeks post‐operatively (28/71 (39.4%)). A higher proportion of Asian and Caucasian women returned to work in eight weeks or less (24/29) compared with black African and Caribbean women (19/42) (p=0.003). Mean number of fibroids removed (2.59; 5.75) was the only significantly differing factor between the two groups (p=0.004). There was a significant difference in BMI and time to return to normal activity between the ≤8 week and >8 week groups (p=0.027; p=0.011). Logistic regression analysis demonstrated that BMI and time to return to normal activity were the only factors prolonging recovery to over eight weeks (p=0.039; p=0.015).ConclusionsTime to return to normal activity and BMI significantly influenced the time taken for women to work after laparoscopic myomectomy. Further data would support clinicians in counseling women appropriately and optimising their post‐operative return to employment.This article is protected by copyright. All rights reserved.
  • Issue Information
  • Celebrating Baer ‐ a Nordic scientist who discovered the mammalian
  • Trends in the incidence rate, type and treatment of surgically verified
           endometriosis – a nationwide cohort study
    • Abstract: IntroductionTo study the trends in incidence rate, type and surgical treatment, and patient characteristics of surgically verified endometriosis during 1987‐2012Material and methodsThis is a register‐based cohort study. We identified women receiving their first diagnosis of endometriosis in surgery from the Finnish Hospital Discharge Register (FHDR). Quality of the FHDR records was assessed bidirectionally. The age‐standardized incidence rates of the first surgically verified endometriosis was assessed by calendar yearResultsThe cohort comprises 49 956 women. The quality assessment suggested the FHDR data to be of good quality. The most common diagnosis, ovarian endometriosis (46%), was associated with highest median age 38.5 years (interquartile range 31.0, 44.8), the second was peritoneal endometriosis (40%) with median age 34.9 years (28.6, 41.7). Between 1987 and 2012, a decrease was observed in the median age (from 38.8 [32.3‐43.6] to 34.0 [28.9, 41.0] years), and in the age‐standardized incidence rate (from 116 [95% confidence interval; 112‐120] to 45 [43‐48] per 100 000 women). The proportion of hysterectomy as a first surgical treatment decreased from 38% to 19% whereas that of laparoscopy increased from 42% to 73% when comparing periods 1987‐1995 to 1996‐2012ConclusionsThis nationwide cohort of surgically verified endometriosis showed a decrease in the incidence rate and in the patient age at the time of first diagnosis even the proportion of laparoscopy has increased. The number of hysterectomies has decreased. These changes are likely to reflect the evolving diagnostics, increasing awareness of endometriosis, and effective use of medical treatment before surgery.This article is protected by copyright. All rights reserved.
  • Microdissection testicular sperm extraction in Finland –results of
           the first 100 patients
    • Abstract: IntroductionTesticular microdissection sperm extraction (MD‐TESE) combined with intracytoplasmic sperm injection (ICSI) has made biological fatherhood possible for many men with the most severe form of male infertility, non‐obstructive azoospermia. MD‐TESE was introduced in Turku in 2008, and by 2015, 100 Finnish men with non‐obstructive azoospermia have been operated on.Material and methodsThe average age was 33 years at the time of surgery. Forty‐eight had a needle biopsy previously, 56% had testicular size less than 15ml. The most common diagnoses were idiopathic (n=65), Klinefelter syndrome (n=15), operated cryptorchidism or torsion (n=10) and Y chromosome microdeletion (n=7). The pregnancy outcomes were followed.ResultsThe sperm recovery rate (SRR) overall was 42%: 31% for idiopathic non‐obstructive azoospermia, 40% for Klinefelter syndrome, 57% for Y chromosome microdeletion AZFc, 90% for previous testicular surgery (mostly for cryptorchidism; n=10) and 67% for previous cytotoxic treatment (n=3). SRR in histopathologic diagnosis Sertoli‐cell‐only was 29%, and 44% in spermatogenic arrest. Age did not affect the outcome of the surgery. Small testicular size seemed to predict a higher SRR. A previous needle biopsy did not predict a lower SRR. Surgical complications were rare. 32 couples had at least one ICSI attempt, and 22 had at least one live birth, giving a cumulative live birth rate of 69%. No major pregnancy complications occurred.ConclusionsOur SRR is comparable with international results, and cumulative live birth rate similar to other ICSI indications in Finland. Physicians and specialists need to be made aware of new treatment options to enable biological fatherhood for men with non‐obstructive azoospermia.This article is protected by copyright. All rights reserved.
  • Antenatal corticosteroid treatment and placental pathology, with a focus
           on villous maturation
    • Abstract: IntroductionMothers at risk of preterm birth are treated with antenatal corticosteroids, which have advantageous effects for prematurely born infants. Accelerated villous maturation in the placenta is also associated with improved perinatal outcome. The primary aim of this study was to examine the association between antenatal corticosteroids and accelerated villous maturation. The secondary aim was to study associations with other placental pathology.Material and methodsA retrospective cohort study including 105 women who had (n=75) or had not (n=30) been treated with antenatal corticosteroids. The women gave birth between 22+0 and 26+6 weeks gestation in Stockholm County between April 1, 2004, and March 31, 2007. A pathologist blinded to all clinical data except gestational age examined the placental slides to identify pathology parameters. The outcomes were correlated with antenatal corticosteroid treatment, and confounding factors were adjusted using logistic regression.ResultsAccelerated villous maturation was significantly higher in the group treated with corticosteroids (odds ratio 16 (95% confidence interval 2.4‐690), p=0.0005). After adjustment for gestational age and preeclampsia, the difference remained significant (odds ratio 8.9 (95% confidence interval 1.2‐389), p=0.021). No significant associations were found regarding the secondary outcome variables, after adjusting for possible confounders.ConclusionsAntenatal corticosteroid treatment before preterm birth is associated with accelerated villous maturation. This could be one of the pathways by which corticosteroids are beneficial for preterm infants.This article is protected by copyright. All rights reserved.
  • Obstetrical complications in dichorionic twin pregnancies in women with
           polycystic ovary syndrome
    • Abstract: IntroductionBoth women with polycystic ovary syndrome (PCOS) and women with twin pregnancies have increased risk of adverse pregnancy outcome. The aim of this study was to investigate the impact of PCOS and maternal androgen levels on the outcome of dichorionic twin pregnancy.Material and methodsA retrospective study of 360 women with dichorionic twin pregnancies: 72 PCOS women from a fertility clinic (years 1997 to 2010) and 288 non‐PCOS women from a hospital cohort (years 2005 to 2007). The obstetrical outcome was extracted from Danish National registers and supplemented by patient file data. 65% of the PCOS group had a registered pre‐pregnancy androgen level and these were stratified into normo‐ and hyperandrogenic women. The groups were compared by multiple regression analysis adjusting for mode of conception and pre‐pregnancy body mass index.ResultsWe found no overall impact of PCOS on the pregnancy outcome; the risk of preeclampsia, gestational diabetes and preterm delivery were comparable within the groups. However, five deliveries in the PCOS group compared to two in the control group occurred before gestational week 28. No difference in the obstetrical outcome between hyperandrogenic and normoandrogenic women was found. The body mass index in the PCOS population was lower than in the non‐PCOS, possibly reflecting a higher socioeconomic status and a healthier lifestyle, which may underestimate the impact of a PCOS diagnosis.ConclusionNeither PCOS nor maternal androgen levels confer additional risks to the outcome of dichorionic twin pregnancies of normal weight women.This article is protected by copyright. All rights reserved.
  • The menstrual cycle and blood loss during laparoscopic myomectomy
    • Abstract: IntroductionOperative morbidity of laparoscopic myomectomy largely relates to the potential for intraoperative blood loss. We sought to determine if blood loss varies according to the menstrual cycle.Material and methodsA retrospective review of 268 women who underwent a laparoscopic myomectomy from 2007 to 2012. Patients were categorized into five menstrual groups: follicular phase, luteal phase, oligomenorrheic or amenorrheic on hormonal therapy, postmenopausal or other. Patient and procedure characteristics were compared for the follicular phase group, luteal phase group, and hormonal therapy group. The estimated blood loss was compared across the five groups using a regression model.ResultsA total of 268 women underwent a laparoscopic myomectomy: 108 (40.3%) were in the follicular phase, 92 (34.3%) were in the luteal phase, 44 (16.4%) were on hormonal therapy, 9 (3.4%) were postmenopausal, and 15 (5.6%) were unable to be classified. Baseline patient characteristics were similar between the groups with the exception of endometriosis. Geometric mean estimated blood loss was 91.9 mL in the follicular phase group, 108.7 mL in the luteal phase group, 114.1 mL in the hormonal therapy group, and 39.8 mL in the postmenopausal group. There was no significant difference in the geometric mean estimated blood loss when comparing the follilcuar phase, luteal phase, and hormonal phase groups (p = 0.41). Upon adjusted multivariable analysis of all five menstrual groups, there was also no difference in estimated blood loss.ConclusionsIntraoperative blood loss during laparoscopic myomectomy does not vary significantly with the phase of the menstrual cycle.This article is protected by copyright. All rights reserved.
  • Differential effect of the ultra‐low dose and standard estrogen plus
           dydrogesterone therapy on thrombin generation and fibrinolysis in
           postmenopausal women
    • Abstract: IntroductionThe objective was to estimate the effects of different doses of oral hormone therapy (HT) on thrombin generation and fibrinolytic activity in postmenopausal women after 12‐months treatment.Material and methodsThrombin generation, fibrinolysis activators and inhibitors were determined before, and after 12‐months treatment. Participants (180) were assigned (1:1:1) as follows: 1) standard HT group, 17β‐estradiol (1 mg/d) with dydrogesterone (5 mg/d); 2) ultra‐low‐dose HT group, 17β‐estradiol (0.5 mg/d) with dydrogesterone (2.5 mg/d); 3) control group, no treatment.ResultsThe standard HT led to higher prothrombin 1+2 fragments concentration (by 5.8%) with lower antithrombin activity (by 6.1%). Compared with baseline, we observed reduction in mean antithrombin activity in the standard HT group and increases in mean prothrombin 1+2 fragments levels in two HT groups. We found decreases after treatment in both standard and ultra‐low‐dose HT groups in plasminogen activator inhibitor‐1 (PAI‐1) activity (‐32.4% and ‐19.6%, respectively) and PAI‐1 antigen (‐9.9% and ‐7.8%, respectively). Intergroup analysis revealed reduction in both mean PAI‐1 activities and PAI‐1 antigen levels in two treatment groups when compared to the control.ConclusionIn contrary to the standard estrogen plus dydrogesterone treatment, ultra‐low‐dose HT revealed positive effects on hemostasis by intensifying fibrinolysis through decrease in both PAI‐1 activity and antigen levels, and with no impact on thrombin generation.This article is protected by copyright. All rights reserved.
  • Improved neonatal outcome after active management of prolonged pregnancies
           beyond 41+2 weeks in nulliparous, but not among multiparous women
    • Abstract: IntroductionProlonged pregnancies are associated with adverse maternal and fetal outcome. In Sweden, no national guidelines exist when to induce prolonged pregnancies.Material and methodsSingleton cephalic prolonged pregnancies (defined as ≥ 41+3 gestational weeks) during 2001‐ 2013 (n=199,770) were identified using the Swedish Medical Birth Register. The maternity units were divided into three groups (tertiles) based on the proportion of pregnancies ≥42+3gestational weeks among all pregnancies ≥41+3 weeks. The pregnancy outcome among women delivered at the units with the most expectant management of prolonged pregnancies (>17.6% proceeding to 42+3 weeks), was compared with that among women delivered at units with the most active management (< 12.6% proceeding to 42+3 weeks). Odds Ratios (OR) were calculated using simple and multiple logistic regression. Adjustments were made for year of delivery, hospital level, maternal age, BMI and smoking.ResultsAmong primiparas, an increased risk of Apgar score < 7 at five minutes (OR=1.27, 95%CI 1.16‐1.41) and meconium aspiration (OR= 1.49, 95%CI 1.14‐1.95) was found after birth at most expectant compared to the most active units, but among multiparas, no such associations were detected. A decreased rate of cesarean section was found for both primiparas (OR= 0.83, 95%CI 0.80‐0.86) and multiparas (OR= 0.82, 95%CI 0.77‐0.86) at units with expectant versus active management. No association between perinatal death and delivery‐unit specific management of prolonged pregnancies was detected.ConclusionsOffspring to primipara might gain from a more active management of prolonged pregnancies, whereas no such improvement of neonatal outcome among multiparous women was detected.This article is protected by copyright. All rights reserved.
  • Diagnostic accuracy of ultrasound in detecting the severity of abnormally
           invasive placentation: a systematic review and meta‐analysis
    • Abstract: IntroductionOur objective was to elucidate the overall diagnostic accuracy of ultrasound in detecting the severity of abnormally invasive placentation (AIP).Material and methodsMedline, Embase, CINAHL and The Cochrane databases were searched. The ultrasound signs explored were: loss of hypoechoic (clear) zone in the placental‐uterine interface, placental lacunae, bladder wall interruption, myometrial thinning, focal exophitic mass, placental lacunar flow, sub‐placental vascularity, and uterovescical hypervascularity.ResultsTwenty studies (3209 pregnancies) were included. Ultrasound had an overall good diagnostic accuracy in identifying the depth of placental invasion with a sensitivity of 90.6%, 93.0%, 89.5% and 81.2% for placenta accreta, increta, accreta/increta and percreta respectively; the corresponding figures for specificity were 97.1%, 98.4%, 94.7%, 98.9%. Placental lacunae had a sensitivity of 74.8%, 88.6% and 76.3% for the detection of placenta accreta, increta and percreta respectively. Sensitivity and specificity of loss of the clear zone in identifying placenta accreta were 74.9% and 92.0%, while the corresponding figures for placenta increta and percreta were 91.6% and 76.9% and 88.1% and 71.1%. Lacunar flow had a sensitivity of 81.2%, 84.3% and 45.2% for the detection of placenta accreta, increta and percreta respectively; the corresponding figures for specificity were 84.0%, 79.7% and 75.3%. Sensitivity of uterovescical hypervascularity was low for the detection of placenta accreta (12.3%) while it was high for placenta increta (94.4%) and percreta (86.2%); the corresponding figures for specificity were 90.8%, 88.0% and 88.2% respectively.ConclusionsUltrasound has an overall good diagnostic accuracy in recognizing the depth and the topography of placental invasion.This article is protected by copyright. All rights reserved.
  • The value of oral micronized progesterone in the prevention of recurrent
           spontaneous preterm birth: a randomized controlled trial
    • Abstract: IntroductionProgesterone is becoming universally accepted for preventing recurrent spontaneous preterm delivery (SPD). There is, however, poor consensus on the effective types and doses of progesterone to be used. Despite the encouraging available research, the role of oral micronized progesterone has not yet been thoroughly investigated.Material and methodsWe randomized 212 singleton pregnancies, with past history of SPD at
  • Weekend‐free scheduled IVF/ICSI procedures and single embryo transfer do
           not reduce live‐birth rates in a general infertile population
    • Abstract: IntroductionScheduling of ovum pickups (OPU) only on weekdays may result in cases of apparently suboptimal timing for human chorionic gonadotropin (hCG) and OPU. This study aimed to assess whether live‐birth rates were reduced in women with a potentially suboptimal day for hCG and OPU to avoid week‐end work, according to ultrasonographic data on the day of hCG planning.Material and methodsAn evaluation of the optimal hCG priming date was performed in treatment protocols of 1000 consecutive patients undergoing their first in vitro fertilization /intracytoplasmatic sperm injection (IVF/ICSI) with single‐embryo transfer. An ideal OPU day was characterized by hCG‐scheduling when ≧3 follicles reached 17mm (day 0) or with one day of delay (day +1) (N=760). A non‐ideal OPU was either early (day ‐1,‐2,‐3) (N=24) or delayed (day +2,+3,+4) (N=216). Live‐birth rates in the ideal and non‐ideal OPU groups was set as primary outcome measure.ResultsEarly‐OPUs were excluded as they were infrequent. No differences between ideal and delayed OPU groups were found regarding number of oocytes retrieved (9.87 vs. 9.78, P=0.990), pregnancy rates (28.3% vs. 29.6%, P=0.701) or live‐birth rates (26.2% vs. 25.9%, P=0.939). However, sub analyses indicated that treatment with gonadotropin releasing hormone antagonists resulted in significantly lower clinical pregnancy rates in delayed OPUs (odds ratio 0.46, p=0.014), compared to agonist treatments.ConclusionsWeekend work may not be needed for IVF/ICSI‐ single‐embryo transfer treatments. However, in gonadotropin releasing hormone antagonist cycles, delaying OPU more than one day may be unfavorable.This article is protected by copyright. All rights reserved.
  • Delayed cord clamping and cord gas analysis at birth
    • Abstract: Delayed cord clamping for at least 60 seconds in both term and preterm babies is a major recent change in clinical care. Delayed cord clamping has several effects on other possible interventions. One of these is the effect of delayed cord clamping on umbilical artery gas analysis. When indicated, umbilical artery gas analysis can safely be done either with early cord clamping, or, probably most of the times it is necessary, during delayed cord clamping with the cord still unclamped. Paired blood samples (one from the umbilical artery and one from the umbilical vein) can be taken from the pulsating and unclamped cord, immediately after birth, during delayed cord clamping, without any effect on either the accuracy of umbilical artery gas analysis or on the transfusion of blood through delayed cord clamping. Umbilical artery gas analysis should instead not be done after delayed cord clamping, since delayed cord clamping alters several acid‐based parameters and lactate values.This article is protected by copyright. All rights reserved.
  • High birth rates despite easy access to contraception and abortion : a
           cross‐sectional study
    • Abstract: IntroductionThe aim was to describe and compare contraceptive use, fertility, birth and abortion rates in the Nordic countries.Material and methodsNational data on births, abortions, fertility rate (1975‐2013), redeemed prescriptions of hormonal contraceptives and sales figures of copper intrauterine devices (2008‐2013) among women 15‐49 years of age in the Nordic countries were collected and analysed.ResultsUse of hormonal contraceptives and copper intrauterine devices varied between 31‐44%. The highest use was in Denmark (39‐44%) and Sweden (40‐42%). Combined hormonal contraception followed by the levonorgestrel‐releasing intrauterine system were the most common methods. During 1975‐2013 abortion rates decreased in Denmark (27‐15/1000 women aged 15‐44) and Finland (20‐10), remained stable in Norway (≈16) and Sweden (≈20) and increased in Iceland (6 ‐15). Birth rates remained stable around 60/1000 women aged 15‐44 in all countries except for Iceland where the birth rate decreased from 95‐65. Abortion rates were highest in the age group 20‐24 years. In the same age group Sweden had a lower contraceptive use (51%) compared to Denmark (59%) and Norway (56%) and a higher abortion rate 33/1000 compared to Denmark (25/1000) and Norway (27/1000).ConclusionsIn contrast to the declining average fertility and birth rates in Europe, rates in the Nordic countries remain high and stable despite high contraceptive use and liberal access to abortion on womens′ request.This article is protected by copyright. All rights reserved.
  • Women's experiences of continuous fetal monitoring – a
           mixed‐methods systematic review
    • Abstract: IntroductionAntepartum stillbirth is often preceded by detectable signs of fetal compromise, including changes in fetal heart rate and movement. It is hypothesised that continuous fetal monitoring could detect these signs more accurately and objectively than current forms of fetal monitoring and allow for timely intervention. This systematic review aimed to explore available evidence on women's experiences of continuous fetal monitoring to investigate its acceptability prior to clinical implementation and to inform clinical studies.Material and methodsSystematic searching of four electronic databases (Embase, PsycINFO, MEDLINE and CINAHL), using key terms defined by initial scoping searches, identified a total of 35 studies. Following title and abstract screening by two independent researchers five studies met the inclusion criteria. Studies were not excluded based on language, methodology or quality assessment. An integrative methodology was used to synthesise qualitative and quantitative data together.ResultsForms of continuous fetal monitoring used included Monica AN24 monitors (n=4) and phonocardiography (n=1). Four main themes were identified: practical limitations of the device, negative emotions, positive perceptions and device implementation. Continuous fetal monitoring was reported to have high levels of participant satisfaction and was preferred by women to intermittent cardiotocography.ConclusionThis review suggests that continuous fetal monitoring is accepted by women. However, it has also highlighted both the paucity and heterogeneity of current studies and suggests further research should be conducted into women's experiences of continuous fetal monitoring before such devices can be used clinically.This article is protected by copyright. All rights reserved.
  • Intrapartum transperineal ultrasound used to predict cases of complicated
           operative (vacuum and forceps) deliveries in nulliparous women
    • Abstract: IntroductionThe objective of this study was to investigate the predictive value of intrapartum transperineal ultrasound in the identification of complicated operative(vacuum or forceps) deliveries in nulliparous women.Material and methodsProspective observational study of nulliparous women with an indication for operative‐delivery who underwent intrapartum transperineal ultrasound before fetal extraction. Managing obstetricians were blinded to the ultrasound data. Intrapartum transperineal ultrasound was performed immediately before blade application, both at rest and concurrently with contractions and active pushing. Operative delivery was classified as complicated when one or more of the following situations occurred: ≥3 tractions;a 3‐4th degree perineal tear; significant bleeding during the episiotomy repair; major tear or significant traumatic neonatal lesion.Results143 nulliparous women were included in the study[82 vacuum‐assisted deliveries and 61 forceps‐assisted deliveries] with 20 fetuses in occiput posterior position. Forty‐seven operative deliveries were classified as complicated deliveries(28 vacuum‐assisted deliveries, 19 forceps‐assisted deliveries). No differences in obstetric, intrapartum or neonatal characteristics were observed between the study groups, with the following exceptions: birth weight (3,229±482 uncomplicated deliveries vs. 3,623±406 complicated deliveries; P
  • Intraoperative cervical treatment does not affect the prevalence of
           vaginal bleeding one year postoperatively after subtotal hysterectomy. A
           register study from the Swedish National Register for Gynecological
    • Abstract: IntroductionThe objectives were to establish the prevalence of persistent vaginal bleeding (PVB) following subtotal hysterectomy, to analyze the effect of intraoperative cervical treatment on the occurrence of PVB and to evaluate the impact of PVB on the patient‐reported opinion concerning result of surgery and medical condition.Material and methodsRetrospective study with data from the Swedish National Register for Gynecological Surgery including 5240 women undergoing subtotal hysterectomy for benign conditions between January 2004 and June 2016. Demographic and clinical data were obtained from the pre‐ and perioperative forms. Data concerning occurrence of PVB, rating of medical condition and contentment with result of surgery were collected from the one‐year inquiry form. Statistical analyses were performed with multivariable logistic regression models. The results are presented as adjusted odd ratios (aORs) and 95% confidence intervals (CI).ResultsPVB occurred in 18.6%. Intraoperative cervical treatment did not affect the frequency of PVB (aOR 1.48 (95%CI; 0.93‐2.37). More than 90% were satisfied with the result of the hysterectomy, but women with PVB were less content compared with those without PVB (aOR 0.42 (95%CI; 0.26‐0.67). The self‐perception of the medical condition did not differ between the women with and without PVB (aOR 1.16 (95%CI; 0.33‐4.12)).ConclusionsNearly two in ten women may expect PVB following subtotal hysterectomy, and cervical treatment intraoperatively did not affect this. More than 90% were satisfied with the result but women with PVB were less content. Preoperative information on this risk of PVB may be important when choosing hysterectomy technique.This article is protected by copyright. All rights reserved.
  • Doppler‐based fetal heart rate analysis markers for the detection of
           early intrauterine growth restriction
    • Abstract: IntroductionOne indicator for fetal risk of mortality is intra‐uterine growth restriction (IUGR). Whether markers reflecting the impact of growth restriction on the cardiovascular system, computed from a Doppler‐derived heart rate signal, would be suitable in its detection antenatally were studiedMaterial and methodsWe used a cardiotocography archive of 1163 IUGR cases and 1163 healthy controls, matched for gestation and gender. We assessed the discriminative power of short‐term variability (STV) and long‐term variability (LTV) of the fetal heart rate, computed over episodes of high and low variation aiming to separate growth‐restricted fetuses from controls. Metrics characterizing the sleep state distribution within a trace were also considered for inclusion into an IUGR detection modelResultsSignificant differences in the risk markers comparing growth‐restricted with healthy fetuses were found. When used in a logistic regression classifier, their performance for identifying IUGR was considerably superior before 34 weeks gestation. LTV in active sleep was superior to STV (AUROC of 72% compared to 71%). Most predictive was the number of minutes in high variation per hour (AUROC of 75%). A multivariate IUGR prediction model improved the AUROC to 76%.ConclusionWe suggest that heart rate variability markers together with surrogate information on sleep states can contribute to the detection of early‐onset IUGR.This article is protected by copyright. All rights reserved.
  • Mortality and causes of death among women with a history of placental
    • Abstract: IntroductionWomen with a history of placental abruption have an increased later morbidity, but not much is known of the later mortality.Material and MethodsData on women with placental abruption (index cohort) between 1969 and 2005 (n=7805) were collected from the Finnish Hospital Discharge Register and the Finnish Medical Birth Register. A matched reference cohort consisted of women without placental abruption (n=23 523). The causes of death were retrieved from the Cause-of-Death Register. Cause-specific mortality was compared by hazard ratios (HR). Standardized mortality ratios were calculated to compare both cohorts with the general female population. The main outcome measure was subsequent mortality.ResultsBy the end of 2013 there were 395 deaths in the index cohort and 863 deaths in the reference cohort. The overall mortality was increased in the index cohort compared with the reference cohort (HR 1.39, 95% confidence interval 1.24–1.57). The index cohort had an increased risk of death from respiratory tract malignancies (HR 1.72, 1.05–2.82), alcohol-related causes (HR 1.84, 1.25–2.72), and external causes (HR 1.63, 1.19–2.22), especially suicide (HR 1.71, 1.07–2.74). The mortality from cardiovascular diseases did not differ. The standardized mortality ratio was increased in the index cohort compared to the general Finnish female population (1.13, 1.02–1.24), especially for respiratory tract malignancies (1.79, 1.16–2.64). The index cohort women tended to die younger than referent women (p
  • Propensity score method for analyzing the effect of labor induction in
           prolonged pregnancy
    • Abstract: IntroductionThere is an ongoing debate on the optimal time of labor induction to reduce the risks associated with prolonged pregnancyMaterial and methodsRegistry-based study of 212,716 term, singleton cephalic deliveries between 2006 and 2012 in Finland comparing the outcomes of labor induction to those of expectant management in five three-day gestational age periods between 40 and 42 weeks (Group 1:40+0-40+2; 2:40+3-40+5;3: 40+6-41+1;4: 41+2-41+4;5: 41+5-42+0). Using Poisson regression, induced deliveries in each of the gestational age periods were compared to all ongoing pregnancies. Propensity score matching was applied to reduce confounding by indicationResultsIn the gestational age groups 1-2 labor induction significantly decreased the risk meconium aspiration syndrome (RR 0.40, 95% CI 0.18-0.91, RR 0.44, 95% CI 0.21-0.91) but in contrast, increased the risk for prolonged hospitalization of a neonate (RR 1.30, 95% CI 1.10-1.54 and RR 1.23, 95% CI 1.03-1.47). In the groups 3-4, labor induction significantly increased the risk for emergency cesarean section (RR 1.17, 95% CI 1.06-1.28 and RR 1.19, 95% CI 1.09-1.29) still reducing the risk for meconium aspiration syndrome. In the group 5, labor induction did not affect the risk for any of the studied outcomes (operative delivery, obstetric trauma, neonatal mortality, respirator treatment, Apgar
  • Longitudinal transvaginal ultrasound evaluation of cesarean scar niche
           incidence and depth in the first two years after single- or double-layer
           uterotomy closure: a randomized controlled trial
    • Abstract: IntroductionCesarean deliveries are the most common abdominal surgery procedure globally, and the optimal way to suture the hysterotomy remains a matter of debate. The aim of this study was to assess the incidence of cesarean scar niches and the depth after single- or double-layer uterine closure.Material and methodsWe performed a randomized controlled trial in which women were allocated to three uterotomy suture techniques: continuous single-layer unlocked, continuous locked single-layer, or double-layer sutures. Transvaginal ultrasound was performed six weeks and 6–24 months after cesarean delivery. Clinicaltrials. gov (NCT02338388).ResultsThe study included 435 women. Six weeks after delivery, the incidence of niche was not significantly different between the groups (p=0.52): 40% for single-layer unlocked, 32% for single-layer locked and 43% for double-layer sutures. The mean±SD niche depths were 3.0±1.4 mm for single-layer unlocked, 3.6±1.7 mm for single-layer locked and 3.3±1.3 mm for double-layer sutures (p=1.0). There were no significant differences (p=0.58) in niche incidence between the three groups at the second ultrasound follow-up: 30% for single-layer unlocked, 23% for single-layer locked and 29% for double-layer sutures. The mean±SD niche depth was 3.1±1.5 mm after single-layer unlocked, 2.8±1.5 mm after single-layer locked and 2.5±1.2 mm after double-layer sutures (p=0.61). There was a trend (p=0.06) for the residual myometrium thickness to be thicker after double-layer repair at the long-term follow-up.ConclusionsThe incidence of cesarean scar niche formation and the niche depth was independent of the hysterotomy closure technique.This article is protected by copyright. All rights reserved.
  • Reduced incidence of neonatal early onset group B streptococcal infection
           after promulgation of guidelines for risk-based intrapartum antibiotic
           prophylaxis in Sweden: analysis of a national population-based cohort
    • Abstract: IntroductionTo investigate the incidence of neonatal early onset group B streptococcal (GBS) infection in Sweden after promulgation of guidelines (2008) for risk factor-based intrapartum antibiotic prophylaxis, and evaluate presence of risk factors and obstetric management in mothers.Material and methodsNational registers were searched for infants with early onset GBS infection during 2006-11. Medical records of cases and case mothers were abstracted. Verified cases of sepsis/meningitis and cases with clinical sepsis/pneumonia were documented, as well as risk factors in case mothers and timeliness of intrapartum antibiotic prophylaxis administration.ResultsThere were 227 cases with verified infection, with an incidence of 0.34 ‰ of live births during the whole period. There was a significant decrease after promulgation of guidelines, from 0.40 to 0.30‰ (OR 0.75, 95% CI; 0.57-0.99). A significant decrease in number of cases with clinical GBS sepsis/pneumonia was also observed. In parturients with ≥1 risk factor the incidence of any GBS infection was reduced by approximately 50% (OR 0.47, 95% CI; 0.35-0.64), yet there were many cases where the opportunity for timely administration of intrapartum antibiotic prophylaxis was missed. In infants of mothers without risk factor there was no reduction in early onset GBS morbidity. The mortality in verified cases was 4,8% (95% CI; 2.1-7.6).ConclusionsThe introduction of national guidelines for risk based intrapartum antibiotic prophylaxis coincided with a significant, 50% risk reduction of neonatal early onset GBS infection in infants of parturients presenting with ≥1 risk factor. A stricter adherence to guidelines could probably have reduced the infant morbidity further.This article is protected by copyright. All rights reserved.
  • Is the incidence of recurrent pregnancy loss increasing': a
           retrospective register-based study in Sweden
    • Abstract: IntroductionThe aim of this study was to estimate the incidence of recurrent pregnancy loss (RPL). The prevalence of RPL defined as ≥3 consecutive miscarriages before gestation week 22, is often stated to be 1%. To our knowledge no study has estimated the incidence of RPL, which might be more informative and clinically relevant than the prevalence.Material and MethodsThis retrospective register-based study was conducted from 2003 until 2012 in Sweden with data provided by the Swedish National Board of Health and Welfare. 6852 women were registered with the diagnoses of RPL in the National Patient Register. The incidence of RPL is the number of new women receiving the RPL diagnosis per year in the numerator and population at risk in the denominator.ResultsFor each year, from 2003 to 2012, the incidence was calculated in two different risk populations, 1) all women aged 18-42 years, and 2) all women registered as being pregnant (deliveries or miscarriages). The average incidence in the study period was 53 per 100 000 (0.05%) in women aged 18-42 years and 650 per 100 000 (0.65%) in women who had achieved pregnancy in the period. The incidence of RPL in the two risk populations increased by 74% and 58%, respectively, during the study period.ConclusionThis study suggests that the incidence of RPL increased during the ten-year period studied. Causes can only be speculated upon in this study design, but might be associated with environmental changes, as the increase was fairly rapid.This article is protected by copyright. All rights reserved.
  • Complications in operative hysteroscopy – is prevention
    • Abstract: Operative hysteroscopy in a hospital setting has revolutionized surgical treatment of benign uterine disorders. It is minimally invasive, cost and time-effective and may spare patients from major surgical interventions. Operative hysteroscopy in a day-case hospital setting is regarded as a safe and well-tolerated procedure with low complication rates. However, prevention of adverse events is crucial in daily practice to optimize patient care. Complications in operative hysteroscopy can be divided into early complications, including bleeding, uterine perforation, infection and fluid overload, or late complications and suboptimal outcomes, such as incomplete resection and intrauterine adhesions. Awareness and knowledge of management of adverse events as well as the use of possible preventative measures will increase the quality and safety of hysteroscopic surgery. The present commentary focuses on these issues as an up to date basis for everyday clinical practice.This article is protected by copyright. All rights reserved.
  • Thrombocalc: Implementation and uptake of personalized postpartum venous
           thromboembolism risk assessment in a high throughput obstetric environment
    • Abstract: IntroductionVenous thromboembolism risk assessment (VTERA) is recommended in all pregnant and postpartum women. Our objective was to develop, pilot and implement a user-friendly electronic VTERA toolMaterials and methodsWe developed ‘Thrombocalc’, an electronic VTERA tool using Microsoft Excel™. Thrombocalc was designed as a score-based tool to facilitate rapid assessment of all women after childbirth. Calculation of a total score estimated risk of venous thromboembolism in line with consensus guidelines. Recommendations for thromboprophylaxis were included in the VTERA output. Implementation was phased. Uptake of the VTERA tool was prospectively assessed by monitoring the proportion of women who gave birth in our institution and had a completed risk assessment. Factors affecting completion and accuracy of risk assessments were also assessedResultsThrombocalc was used to prospectively risk assess 8380 women between September 2014 and December 2015. Compliance with this tool increased dramatically throughout the study period; over 92% of women were risk assessed in the last quarter of data collection. Compliance was not adversely affected if delivery took place out of working hours (aOR 1.14, 95% CI; 1.04-1.25). Risk assessment was less likely in the case of caesarean deliveries (aOR=0.66, 95% CI 0.60-0.73) and stillborn infants (aOR=0.48, 95% CI; 0.29-0.79). Misclassification of risk factors led to approximately 207 (2.5%) inaccurate thromboprophylaxis recommendationsConclusionOur electronic, score-based VTERA tool, provides a highly effective mechanism for rapid, assessment of individual postpartum venous thromboembolism risk in a high throughput environment.This article is protected by copyright. All rights reserved.
  • Declining prevalence of cytological squamous intraepithelial lesions of
           the cervix among women living with well-controlled HIV – Most women
           living with HIV do not need annual PAP smear screening
    • Abstract: IntroductionCervical screening by means of annual Papanicolaou (PAP) smears has been recommended for all women living with HIV. We analysed the results of our annual PAP smear screening programme in order to identify low-risk subgroups for less rigorous screeningMaterial and methodsThe study comprised 369 women followed at the Helsinki University Hospital 2002–2013, with a total of 2033 PAP smear results. We analysed the temporal changes in PAP smear findings. Logistic regression analysis for binominal dependent variables was used for assessing risk factors for ever having cytological SIL (hereafter referred as SIL) using Generalized Estimating Equations taking into account multiple observations of each patientResultsMost women had well-controlled HIV especially towards the end of the study. PAP smear results improved substantially. At the time of each individual's last PAP-smear, 90.0% of the findings displayed normal results. Conversely, the rate of SIL decreased from 16.8% to 4.6% from 2002 to 2013. In multivariate analysis the risk of SIL was significantly lower in women with consecutive normal PAP smear findings during the first two years of follow-up (OR 0.21, 95% CI; 0.10–0.45, p500 cells/μL (OR 0.11, 95% CI; 0.05–0.26, p
  • Comparing the accuracy of maternal, clinical, and ultrasound estimations
           to predict birthweight: a meta-analysis
    • Abstract: IntroductionAccurate prediction of birthweight prior to delivery is necessary to establish periconceptional strategies to reduce the rates of adverse pregnancy outcomes. This study was performed to determine whether maternal, clinical, or ultrasound estimation provides the best predictor of birthweightMaterial and methodsMeta-analysis was performed to summarize the relative ratios of the rate of one of maternal, clinical, and ultrasound estimation within 10% of actual birthweight to that of each of the others within the same range and the difference in correlation coefficient of actual birthweight between clinical and ultrasound estimations. Study quality was assessed with regard to the representativeness of participants, verification bias, and review bias. Publication bias was assessed using Egger's testResultsThirty-seven relatively good quality studies were included in the analysis. There was no significant difference in the rates of estimates within 10% of actual birthweight between clinical and maternal estimations (n = 8 and P = 0.491) or between ultrasound and maternal estimations (n = 6 and P = 0.568), or in the correlation coefficient of actual birthweight with ultrasound estimation compared with clinical estimation (n = 5 and P = 0.621). However, the rate of ultrasound estimations within 10% of actual birthweight was significantly higher than that of clinical estimations (n = 18 and P = 0.033). The data showed no publication bias (P = 0.058 – 0.854)ConclusionsUltrasound estimation may be the best predictor of birthweight.This article is protected by copyright. All rights reserved.
  • Adjustable mini-sling compared to conventional mid-urethral slings in
           women with urinary incontinence. A randomized controlled trial
    • Abstract: IntroductionThe primary aim was to compare the objective and subjective outcomes and short-term complication rates of an adjustable single-incision mini-sling (SIMS) versus standard mid-urethral slings (SMUS). The secondary aim was reporting pain perception and complications at one-year follow-up.Material and methodsThe study was designed as a multicenter prospective randomized trial where women were included by eight centers in Denmark, Norway and Sweden. The trial was registered at ClinicalTrials. gov: NCT01754558. A total of 305 women less than 60 years old with verified stress urinary incontinence were included. All women were randomized to SIMS (Ajust®; N=155) or SMUS (TVT, TVT-O or TOT; N=150) and were evaluated by stress test and bladder diary before and after surgery and symptoms related to incontinence using ICIQ-SF, PISQ-12 and PGI-S and PGI-I. Objective cure was defined as no leakage during a stress test and subjective cure defined as no leakage stated in the bladder diary or no indication of urinary leakage in the ICIQ-SF. Furthermore, mesh exposure and dyspareunia were recorded.ResultsIn total 280 women (141 (91%) in the SIMS and 139 (94%) in the SMUS groups) participated in the one-year follow-up. No difference between the groups was observed regarding objective and subjective outcomes. VAS score disclosed a lower postoperative pain perception in the SIMS group compared to the SMUS group.ConclusionsAjust® appears to be as efficient as SMUS regarding objective and subjective outcomes and was associated with less pain perception during the postoperative period.This article is protected by copyright. All rights reserved.
  • Fertility preservation in women with borderline ovarian tumors- how does
           it impact disease outcome' A cohort study
    • Abstract: IntroductionBorderline ovarian tumors are typically indolent neoplasms. Since many are diagnosed in younger women, fertility conservation is an important consideration and has been advocated based on retrospective data. The objective of this study was to identify features impacting on recurrence and survival in a series of borderline ovarian tumors, and to assess the safety of a fertility-sparing approach.Material and methodsA historical cohort study of consecutive borderline ovarian tumors cases treated at a single institution over 30 years (1981-2011). Data on surgical approach (fertility sparing or otherwise), disease stage, CA125 levels, histological features, adjuvant treatment and follow up data were collected. Recurrence and survival were assessed using the Kaplan Meier method and associations with the variables of interest were evaluated using a multivariate Cox proportional hazards model.Results213 patients were included. Of 132 women age 40 years and below at diagnosis, 112 (85%) had a fertility-sparing procedure and 60 (46%) had conservation of an involved ovary. Fifty patients (24%) developed recurrences; fertility preservation (hazard ratio= 2.57; CI 1.1-6; p=0.029) and advanced stage (hazard ratio=4.15; CI 2.3-7.6; p
  • Sequence variants in ESR1 and OXTR are associated with
           Mayer-Rokitansky-Küster-Hauser syndrome
    • Abstract: IntroductionMayer-Rokitansky-Küster-Hauser syndrome (MRKHS) is characterized by congenital absence of the uterus and the upper two-thirds of the vagina in otherwise phenotypically normal females. It is found isolated or associated with renal, skeletal and other malformations. Despite of ongoing research, the etiology is mainly unknown. For a long time, the hypothesis of deficient hormone receptors as cause for MRKHS exists, and is supported by previous findings of our group. The aim of the present study was to identify unknown genetic causes for MRKHS and to compare them with data banks including a review of the literature.Material and methodsDNA sequence analysis of the oxytocin receptor (OXTR) and estrogen receptor-1 gene (ESR1) was performed in a group of 93 clinically well-defined patients with uterovaginal aplasia (68 with the isolated form and 25 with associated malformations).ResultsIn total, we detected three OXTR variants in 18 MRKHS patients with one leading to a missense mutation, and six ESR1 variants in 21 MRKHS patients, two of these causing amino acid changes and therefore potentially disease causing.ConclusionsThe identified variants on DNA level might impair receptor function through different molecular mechanisms. Mutations of ESR1 and OXTR are associated with MRKHS. Thus, we consider these genes as potential candidates in the manifestation of MRKHS.This article is protected by copyright. All rights reserved.
  • Maternal and neonatal outcomes following abnormally invasive placenta: a
           population-based record linkage study
    • Abstract: IntroductionAbnormally invasive placenta (AIP) involves abnormal adherence of the placenta to the myometrium, and is associated with severe pregnancy complications such as blood transfusion and hysterectomy. Knowledge of outcomes has been limited by small sample sizes and a focus on maternal rather than neonatal outcomes. This study uses population-level data collected over ten years to investigate maternal and neonatal outcomes and trends in incidence of AIP (also known as placenta accreta, increta and percreta).Material and methodsA population-based record linkage study was performed, including all women who gave birth in New South Wales, Australia, between 2003 and 2012. Data were obtained from birth records, hospital admissions and deaths registrations. Modified Poisson regression models were used to quantify the effect of AIP on adverse maternal and neonatal outcomes.ResultsAbnormally invasive placenta was significantly associated with morbidity for mothers (aRR 17.6, 99%CI; 14.5-21.2) and infants (aRR 3.1, 99%CI; 2.7-3.5). AIP increased risk of stillbirth (RR 5.4, 99%CI; 4.0-7.3) and neonatal death (RR 8.0, 99%CI; 1.5-41.6). The overall rate of AIP was 24.8 per 10,000 deliveries, and 22.7 per 10,000 among primiparae. Incidence increased by 30%, from 20.6 to 26.9 per 10,000 over the ten-year study period.ConclusionsAbnormally invasive placenta substantially increases risk of severe adverse outcomes for mothers and babies, and incidence is increasing. Delivery should occur in tertiary hospitals equipped with neonatal intensive care units. Clinicians should be cognizant of the risks, particularly to infants, and maintain a high index of suspicion of AIP, including in primiparae.This article is protected by copyright. All rights reserved.
  • Insulin resistance in pregnant women with and without polycystic ovary
           syndrome, and measures of body composition in offspring at birth and 3
           years of age
    • Abstract: IntroductionPolycystic ovary syndrome (PCOS) is associated with obesity and insulin resistance in the non-pregnant state, but little is known about insulin sensitivity in the pregnant state. Our objective was to compare insulin resistance in pregnant women with and without PCOS and explore the impact of PCOS on body composition in offspring at birth and at 3 years of ageMaterial and methodsA prospective cohort study including 2548 live born singleton mother-child pairs residing in Odense municipality, Denmark, during 2010-2013. Of the 2548 women, 241 (9.4%) had PCOSResultsHomeostatic model assessment for insulin resistance (HOMA-IR) assessments were comparable in women with and without PCOS. However, the subgroup of overweight women with PCOS had significantly higher levels of HOMA-IR than overweight women without PCOS (mean ±2SD): 4.4 (3.1) vs. 3.6 (3.4), p = 0.004. Maternal PCOS did not affect offspring birthweight after accounting for age. PCOS, adjusted for maternal BMI, was however, associated with increased BMI at 3 years of age (mean ±2SD): 16.0 (2.2) vs. 15.7 (2.1) kg/m2, p = 0.04ConclusionIn our cohort, maternal PCOS was not associated with insulin resistance after correcting for BMI and was not an independent predictor of offspring birthweight. However, both PCOS and high maternal BMI may increase risk of childhood obesity at 3 years of age.This article is protected by copyright. All rights reserved.
  • E-cigarette use in pregnancy: a human rights-based approach to policy and
    • Abstract: The health risks associated with e-cigarette use in pregnancy are mostly unknown. Guidelines by the World Health Organization and national health agencies warn women against using e-cigarettes in pregnancy, however, in the UK, a recent multiagency guideline takes a different approach by not discouraging e-cigarette use in pregnancy. Furthermore, e-Voke™, an e-cigarette, has been approved for use in pregnancy in the UK. We analyze United Nations’ human rights treaties to examine how they might inform best practice recommendations for e-cigarette use in pregnancy. These treaties oblige Parties to adopt policies that protect children's and women's right to health, appropriate pregnancy services, and health education. We argue that clinical practice guidelines related to use of e-cigarettes in pregnancy should consider both evidence and human rights principles, and ensure that healthcare providers and patients are given clear, accurate messages about the known and potential risks associated with e-cigarette use in pregnancy.This article is protected by copyright. All rights reserved.
  • Prematurity and neonatal outcome including congenital malformations after
           maternal malignancy within six months prior or during pregnancy
    • Abstract: IntroductionThe proportion of women who postpone childbearing is increasing. As malignancy risk increases with age, pregnancy in connection with malignancy will become more common.Material and methodsWe compared infants born 1994-2011 to women with a malignancy within six months prior to the last menstrual period or during pregnancy with offspring of women without a previous malignancy. Five national registers were usedResultsA total of 790 women with a malignancy diagnosis from six months prior to the last menstrual period up to delivery were identified. Their 802 infants were compared with 1 742 757 infants of women without a malignancy. A high rate of prematurity was found, especially when the malignancy was diagnosed during the 2nd or 3rd trimesters (33%). Most of these premature births were the result of induced delivery before 35 weeks (91%). The most remarkable finding is the observation that these premature infants had a significantly higher risk for neonatal morbidity than premature infants in the control group with an adjusted odds ratio of 2.67 (95% confidence interval; 1.86-3.84). We found a significantly increased risk of mainly relatively mild malformations among infants of women with a malignancy diagnosis within six months prior to the last menstrual period or during the first trimester with a risk ratio of 1.81 (95% confidence interval; 1.20-2.61)ConclusionsA high incidence of prematurity, mostly due to induced delivery, was found including an increased risk for neonatal morbidity among these infants. An increased risk for relatively mild malformations was also found.This article is protected by copyright. All rights reserved.
  • The fetuses-at-risk approach: survival analysis from a fetal perspective
    • Abstract: Several phenomena in contemporary perinatology create challenges for analyzing pregnancy outcomes. These include recent increases in iatrogenic delivery at late preterm and early term gestation which are incongruent with the belief that stillbirth and neonatal death risk decrease exponentially with advancing gestational age. Perinatal epidemiologists have also puzzled over the paradox of intersecting birth weight- and gestational age-specific perinatal mortality curves for decades. For example, neonatal mortality rates among preterm infants of women who smoke are substantially lower than neonatal mortality rates among preterm infants of non-smoking women, whereas the reverse pattern occurs at term gestation. This mortality crossover is observed across several contrasts (women with hypertensive disorders of pregnancy vs normotensive women, older vs younger women, twins vs singletons, etc.) and outcomes (stillbirth, neonatal death, sudden infant death syndrome and cerebral palsy), and irrespective of how advancing “maturity” is defined (birth weight or gestational age). One approach proposed to address and explain these unexpected phenomena is the fetuses-at-risk model. This formulation involves a reconceptualization of the denominator for perinatal outcome rates from births to surviving fetuses. In this overview of the fetuses-at-risk model, we discuss the central tenets of the births-based and the fetuses-based formulations. We also describe the extension of the fetuses-at-risk approach to outcomes into and beyond the neonatal period and to a multivariable adaptation. Finally, we provide a substantive context by discussing biological mechanisms underlying the fetuses-at-risk model and contemporary obstetric phenomena that are better understood from that model than from one based on births.This article is protected by copyright. All rights reserved.
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