Acta Obstetricia et Gynecologica Scandinavica最新文献

Introduction: Twin pregnancies impose greater cardiovascular demands than singleton gestations, potentially increasing long-term cardiovascular risk even in the absence of hypertensive disorders. Nevertheless, longitudinal assessments of maternal hemodynamics in uncomplicated twin pregnancies remain limited, and most available studies focus solely on the antenatal period. Chorionicity has been shown to markedly influence cardiovascular adaptation during twin gestation. This study aimed to investigate whether distinct hemodynamic adaptations occur in twin compared with singleton pregnancies during late gestation, 1 day and 6 weeks postpartum.

Material and methods: In this prospective longitudinal cohort study conducted at Hannover Medical School from 08/24 to 05/2025, 36 women with twin pregnancies (8 monochorionic (MC), 28 dichorionic (DC)) and 37 with singleton pregnancies underwent noninvasive hemodynamic assessment at 34 weeks' gestation, 1 day postpartum, and 6 weeks postpartum.

Results: MC twin pregnancies exhibited significantly higher cardiac output (MC: 7.72 L/min; DC: 5.62 L/min; S: 6.27 L/min; p = 0.01) and lower systemic vascular resistance (MC: 958.83 dynes × s/cm⁵; DC: 1206.86 dynes × s/cm⁵; S: 1119.45 dynes × s/cm⁵; p = 0.01) during the third trimester, with a similar hemodynamic pattern appearing to persist in the postpartum period. MC twins also showed significant decreases in heart rate (T1: 86.37 bpm; T2: 77.73 bpm; T3: 66.67 bpm; p = 0.002), mean arterial pressure (T1: 93.0 mmHg; T2: 85.5 mmHg; T3: 78.0 mmHg; p = 0.03), and inotropism postpartum (T1: 1.92 W/m²; T2: 1.67 W/m²; T3: 1.54 W/m²; p = 0.04), whereas DC twins demonstrated a trend to higher stroke volume (T1: 69.6 mL; T2: 80.31 mL; T3: 82.63 mL; p = 0.01) and gradual increase of vascular resistance (T1: 1206.86 dynes × s/cm⁵; T2:1099.86 dynes × s/cm⁵; T3: 1426.78 dynes × s/cm⁵; p = 0.08).

Conclusions: Monochorionic twin pregnancies are characterized by elevated cardiac output and reduced vascular resistance in late pregnancy, with a similar hemodynamic pattern appearing to persist in the postpartum period. This persistent cardiovascular strain may underlie the elevated short-term cardiovascular risk observed after twin births. Our findings highlight the need for larger longitudinal studies to explore the transition from physiological adaptation to potential cardiovascular maladaptation.

Introduction: Adhesion molecules are markers of endothelial activation, and they are involved in placentation and inflammation. We compared levels of vascular cell adhesion molecule-1 (VCAM1), intercellular adhesion molecule-1 (ICAM1), and E-selectin (SELE) in maternal and fetal vessels of preeclampsia and healthy pregnancies. Furthermore, we investigated if the placenta releases adhesion molecules.

Material and methods: Blood was sampled from three maternal (antecubital vein, uterine vein, and radial artery as a proxy for the uterine artery) and two fetal vessels (umbilical vein and artery) in 75 healthy pregnancies and 37 cases of preeclampsia undergoing cesarean delivery. Samples were also collected among 70 healthy pregnancies and 35 preeclampsia cases at three visits (gestational weeks 14-16, 22-24, and 30-32) in a longitudinal cohort. Proteins were relatively quantified on SomaLogic's 5000-multiplex platform. Venoarterial differences on both sides of the placenta were used to indicate placental release and uptake.

Results: Before the onset of preeclampsia, we observed elevated maternal antecubital vein levels of VCAM1 (visits 1 and 3) and ICAM1 (all three visits). At delivery, VCAM1 and SELE were elevated in maternal vessels in preeclampsia compared to healthy, except for VCAM1 in the uterine vein. On the fetal side of the placenta, adhesion molecules were lower in preeclampsia compared to healthy pregnancies. There were no venoarterial differences on the maternal side of the placenta that indicated placental protein release. On the fetal side of the placenta, healthy controls had a positive venoarterial difference of SELE, indicating placental release to the fetus. VCAM1 and SELE levels were higher in fetal circulation as compared to maternal circulation in healthy pregnancies, whereas in preeclampsia, this was only the case for VCAM1. ICAM1 was higher in maternal than fetal circulation in healthy controls and preeclampsia.

Conclusions: Alterations in maternal levels of adhesion molecules were seen before the onset of PE. In preeclampsia, adhesion molecules were elevated in the maternal and lower in the fetal circulation. There was no placental release of the adhesion molecules to the mother, indicating a general systemic endothelial dysfunction. The results highlight new insights into the pathophysiology of preeclampsia that warrant further exploration.

Introduction: Perineal tears are classified into four degrees based on severity. Second-degree tears, which involve the muscles fusing into the perineal body, but not the anal sphincter, vary in extent and have recently been subcategorized. However, knowledge about their long-term anatomical impact on the perineal body remains limited, as postpartum evaluation has largely relied on inspection and palpation. This study aimed to examine the association between the severity of perineal tears not affecting the anal sphincter, diagnosed at delivery, and deviations in the muscles fusing into the perineal body, assessed by three-dimensional ultrasound 1 year after vaginal delivery.

Material and methods: This prospective cohort study included 384 primiparous women with vaginal deliveries at Akershus University Hospital, Norway, from January 2021 to July 2022. Perineal tears were classified and sutured according to international standards at delivery. In addition, second-degree tears were subclassified according to the percentage of the perineal body damage (<50% = 2A, ≥50% = 2B, entire perineal body without anal sphincter = 2C). Women with third- or fourth-degree tears were excluded. One year after delivery, participants underwent three-dimensional endovaginal and endoanal ultrasound examinations. The transverse perineal, puboperinealis, and puboanalis muscles were examined at their fusion into the perineal body. A deviation was defined as a muscle discontinuity or absence in at least one of the muscles.

Results: The proportion of women with sonographically detected muscle deviations increased with tear severity: 22% for first-degree (n = 24), 52.7% for 2A (n = 29), 60% for 2B (n = 21) and 86.2% for 2C (n = 25). Among women with episiotomies (n = 126), 60.6% had one or more muscle deviations. A higher number of muscles were affected in the 2C tear group compared to 2B and 2A.

Conclusion: Sonographic deviations in the muscles fusing into the perineal body increase with the severity of perineal tears.

Introduction: Brachial plexus injury (BPI) is one of the major complications associated with shoulder dystocia. This study aimed to identify risk factors for shoulder dystocia-related BPI (SD BPI) in the Finnish population.

Material and methods: The study included all deliveries in the Hospital District of Helsinki and Uusimaa between 2006 and 2015 (n = 181 352). Singleton deliveries complicated by shoulder dystocia, BPI, and clavicle fracture were identified using ICD-10 codes O66.0, P13.4, P14.0, and P14.1 (n = 1708). Following a thorough review of medical records, 374 cases of BPI were identified, 259 of which were related to shoulder dystocia. The background-matched control group (n = 566) consisted of singleton deliveries without BPI.

Results: The incidences of both BPI with and without shoulder dystocia declined significantly during the study period, from 0.16% to 0.05% and from 0.09% to 0.03%, respectively. Multivariate analysis identified the following independent risk factors for SD BPI: birthweight ≥4000 g (adjusted odds ratio, aOR 15.3), maternal diabetes (aOR 4.0), vacuum extraction (aOR 3.7), and maternal height ≤160 cm (aOR 2.7). A predictive model based on these four risk factors demonstrated a positive predictive value of 48.2% and a negative predictive value of 92.9% for SD BPI cases. The odds of permanent BPI were 2.5-fold for cases associated with shoulder dystocia compared to those without. Antepartum and intrapartum variables were not predictive of permanent SD BPI. Among all BPI cases, 69.3% were associated with shoulder dystocia and 64.2% with birthweight ≥4000 g.

Conclusions: Birthweight ≥4000 g, maternal diabetes, height ≤160 cm, and vacuum extraction independently increased the risk of SD BPI. Notably, 14.7% of all BPI cases occurred in the absence of both shoulder dystocia and birthweight ≥4000 g.

Introduction: Small fetal size is the most important risk factor for stillbirth. To our knowledge, no previous study has considered combinations of mid-trimester measures of fetal size as predictors of stillbirth risk. The aim of this cohort study was to assess whether small fetal measurements by mid-pregnancy ultrasound, in conjunction with maternal factors, can predict the risk of stillbirth.

Material and methods: In this historical cohort study, we identified 377 563 singleton pregnancies in the Swedish Pregnancy Register between 2014 and 2021, with delivery at ≥22⁺⁰ gestational weeks with a first trimester (6⁺⁰-13⁺⁶ weeks) dating ultrasound, and second trimester (16⁺⁰-21⁺⁶ weeks) measurements of biparietal diameter (BPD), abdominal circumference (AC), and femur length (FL). Relative risks (RR) with a 95% confidence interval (CI) for stillbirth were calculated for fetuses with any second-trimester biometry <5th centile, and adjusted for maternal characteristics. Odds ratios (ORs) with 95% CI were used to assess the individual contributions of fetal biometry and maternal characteristics to stillbirth risk. Significant factors were included in a multivariate prediction model, and the area under the receiver operating characteristic curve (AUC) was used to assess predictive performance.

Results: Short second-trimester FL was associated with increased risk of stillbirth, especially when combined with small AC or both small BPD and AC (aRR [95% CI] 2.78 [1.44-5.34] and 2.40 [1.14-5.06], respectively), whereas normal FL with small BPD and/or AC was not. In the multivariable model, short FL in combination with small AC was the strongest contributor to stillbirth risk assessment. The AUC of the prediction model, including both maternal characteristics, small AC, and short FL, was 0.623 for stillbirth in all pregnancies, 0.635 for term stillbirth, and 0.591 for preterm stillbirth.

Conclusions: We found evidence of increased risk of stillbirth among fetuses with short FL, especially in combination with small AC, but not with normal FL, regardless of other small fetal dimensions. However, maternal characteristics and mid-gestational biometry perform poorly in predicting stillbirth.

Introduction: At Kuopio University Hospital (KUH), the rate of fetal blood sampling (FBS) among women undergoing a trial of labor has markedly decreased over the past 20 years. The aim of this study was to evaluate the association of this decline with birth outcomes and how maternal and delivery characteristics have changed over the extended study period.

Material and methods: This retrospective registry-based study included 40 309 singleton pregnancies with a live vertex-presenting fetus at or beyond 33 weeks of gestation with a trial of labor and deliveries between January 2002 and December 2021. Prenatal and birth data were obtained from the KUH birth registry, and variables were analyzed across four intervals of 5 years. The evaluated birth outcomes included the mode of delivery, labor induction, meconium-stained or bloody amniotic fluid, birthweight, 5-min Apgar scores, physician-diagnosed asphyxia, perinatal death, and admission to the neonatal intensive care unit (NICU).

Results: During the 20-year study period, intrapartum FBS was performed in 3486 cases (8.6%), while 36 823 women (91.4%) delivered without FBS. The use of FBS declined from 11.7% to 3.9% (p < 0.001). Concurrently, the rate of spontaneous vaginal deliveries increased from 83.6% to 87.6%, whereas nonelective cesarean deliveries decreased from 8.4% to 4.3%. Fewer newborns were diagnosed with asphyxia by physicians and admitted to the NICU. However, the incidence of low 5-min Apgar scores (<7) peaked with a 77.8% increase during the last study period compared to the preceding one, coinciding with the lowest rate of FBS use. General trends included declines in birth rate, maternal smoking, and gestational age at birth, as well as increases in maternal age, body mass index, and the rate of labor induction.

Conclusions: The change in FBS rate may reflect evolving clinical assessment criteria and more stringent selection strategies for its use. However, it may also be associated with an increased number of cases presenting with low Apgar scores.