Acta Obstetricia et Gynecologica Scandinavica最新文献

Introduction: Our objectives were to evaluate the association between fetal growth abnormalities and adverse perinatal outcomes in term pregnancies using four different fetal growth references: the recently published Swedish references by Lindström et al., the currently used Swedish references by Maršál et al., and the international standards by the WHO and INTERGROWTH-21st (IG21st). The study aimed to evaluate the performance of each reference and determine which reference most accurately identifies small for gestational age (SGA) infants at risk of perinatal mortality and morbidity.

Material and methods: This population-based cohort study included 1 126 059 singleton term births in Sweden from 2010 to 2020. Data were obtained from national registers, including the Swedish Medical Birth Register and the Swedish Neonatal Quality Register. Birthweight centiles were calculated using each growth reference. Adverse perinatal outcomes were categorized by severity and included stillbirth, neonatal death, and serious neonatal morbidity. Logistic regression models were used to assess predictive performance, and sensitivity and false positive rates (FPR) were calculated for SGA thresholds (<3rd and <10th centiles).

Results: The distribution of birthweight centiles varied significantly across references. For SGA <3rd centile, the rate ranged from 9.6% for Lindström, 2.5% for Maršál, 1.9% for WHO, to 0.7% for IG21st. All references showed similar overall predictive performance (C-index ≈ 0.67) but with different discriminatory ability. The predicted risk of perinatal death increased at lower centiles for the Lindström reference than for the Maršál and WHO references, and at higher centiles for the IG21st reference. The Lindström reference identified the highest proportion of infants as SGA and had the highest sensitivity but also the highest FPR for detecting adverse outcomes. The IG21st reference classified the smallest proportion as SGA, resulting in the lowest sensitivity and FPR.

Conclusions: While all fetal growth references showed comparable predictive ability for adverse perinatal outcomes, they differed substantially in sensitivity and FPR. When the top priority is to identify as many at-risk fetuses as possible, Lindström et al.'s reference seems to be the best choice. However, when the top priority is a balanced sensitivity versus FPR, the WHO reference seems most suitable for clinical practice in this population of term births.

Introduction: Laparoscopic cervical cerclage is an intervention for the prevention of preterm birth, for example, in women with a weak cervix due to prior cervical surgery or prior failed vaginal cerclage. Little is known about pregnancy outcomes when a cerclage is left in situ across consecutive pregnancies; this study aims to investigate neonatal outcomes following laparoscopic cervical cerclage placement in first and subsequent pregnancies and to compare pre- and postconception placement of the laparoscopic cervical cerclage on neonatal survival.

Material and methods: We performed an observational study in women who had a laparoscopic cervical cerclage at Aarhus University Hospital, Denmark, between 2011 and 2021. Data on the timing of the procedure (pre- vs post-conception), surgical complications, obstetric, and neonatal outcomes were collected from electronic patient records and analyzed descriptively. The primary outcome was neonatal survival. Secondary outcomes were neonatal survival without major morbidity, preterm birth, and gestational age at birth.

Results: A total of 170 women had a laparoscopic cervical cerclage during the study period. Uterine wall perforation occurred in 10/170 procedures (6%), postoperative infection in 4/170 (2%), and 125/170 (74%) were discharged on the same day as the procedure. There were 145 women with at least one subsequent pregnancy and 229 registered pregnancies in total. In the 185 pregnancies that progressed beyond 20 weeks, 166/181 (92%) delivered ≥34 weeks of gestation. Neonatal survival was 183/186 (98%), and survival without major morbidity was 181/186 (97%). Neonatal outcomes were similar between women with a cerclage placed pre- or postconception. Fifty of 145 women (34%) with a cerclage left in situ had more than one pregnancy beyond 20 weeks of gestation. These repeated pregnancies showed consistently favorable outcomes, with neonatal survival rates of 100% in second pregnancies (44/44) and 100% in third pregnancies (4/4).

Conclusions: Laparoscopic cervical cerclage supports favorable neonatal outcomes in first and subsequent pregnancies. Neonatal outcomes did not appear to differ based on whether the cerclage was placed pre- or postconception. Pregnancies in which the cerclage was left in situ demonstrated high neonatal survival rates and favorable obstetric outcomes in both second and third pregnancies.

Introduction: The global cesarean section (CS) rate has increased to 21.1% between 1990 and 2018. In Singapore, the annual CS rate has increased by ~ 0.6%, reaching an overall rate of 37.4%. Almost one-third of all cesarean deliveries are performed for at least one previous CS. Women with two CSs are often denied a "trial of vaginal delivery" due to the increased risk of uterine scar rupture. This study aims to examine maternal and neonatal outcomes of women undergoing trials of labor following two CSs (TOLAC-2).

Material and methods: We conducted a retrospective observational study of women with singleton, term pregnancies in cephalic presentation who underwent TOLAC-2 at the National University Hospital, Singapore, between September 2013 and June 2022. Data were obtained through a detailed review of electronic medical records.

Results: Among 898 women with two previous CSs, 7.0% (63/898) attempted TOLAC-2, of whom 55.6% (35/63) achieved a successful vaginal birth (VBAC-2). Successful TOLAC-2 was associated with a significantly shorter duration of active labor (5.0 vs. 7.7 h, p = 0.013) and lower estimated blood loss (242mLs vs. 423mLs, p ≤ 0.001) compared with failed TOLAC-2. There were no perinatal complications of uterine rupture, APGAR <7 at 5 minutes, meconium aspiration syndrome or hypoxic-ischemic encephalopathy. We observed a trend toward successful VBAC-2 in women with a history of prior vaginal birth (74.6% vs. 48.9% p = 0.07).

Conclusions: In our cohort, more than half of the women attempting TOLAC-2 at term achieved a successful vaginal birth without serious perinatal or maternal complications. TOLAC-2 is a safe and reasonable option for appropriately selected women following adequate counseling, even in the absence of a prior vaginal delivery.

Introduction: Recurrent implantation failure (RIF) is a multifactorial reproductive disorder, often associated with chronic endometritis (CE) and alterations of the intrauterine microbiota.

Material and methods: This systematic review evaluated whether microbiota-targeted therapeutic interventions improve pregnancy outcomes in women with CE-associated RIF undergoing in vitro fertilization (IVF)-embryo transfer (ET). Study quality and risk of bias were assessed using the Newcastle-Ottawa Scale (NOS) and the Revised Cochrane Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I).

Results: Four studies met the inclusion criteria, encompassing antibiotic, probiotic, and nutraceutical interventions. Considerable heterogeneity was observed in study design, diagnostic criteria, and microbiota assessment methods. Across studies, the reproductive outcomes revealed a clinical pregnancy rate of 50.5% (187/370), ongoing pregnancy rate of 40.1% (107/267), and live birth rate of 41.2% (105/255). Other reported outcomes included seven multiple pregnancies (8.3%), 39 miscarriages (20.0%), 35 biochemical pregnancies (17.9%), and one stillbirth (1.17%).

Conclusions: Microbiota-targeted treatments may improve reproductive outcomes in women with CE-associated RIF; however, the limited number of available studies, small sample sizes, and methodological variability reduce the strength of current evidence. High-quality, prospective, confounder-adjusted trials with rigorous participant selection processes and standardized, validated diagnostic and implementation criteria are needed to confirm these findings and inform clinical practice.

Introduction: Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a technique combining vaginal entrance to the abdomen with endoscopic overview. Previous studies have shown that vNOTES decreases operating time, hospitalization, postoperative complications, and pain. We aimed to present patient demographics, costs, and surgical outcomes following the implementation of vNOTES for benign hysterectomies in Sweden.

Material and methods: We conducted a historical cohort study with the first vNOTES hysterectomies in Sweden 2021-2023 involving 8 hospitals. Data was extracted from the Swedish National Quality Register for Gynecological Surgery (GynOp). Our main outcomes were intraoperative and postoperative complications, costs, and patient satisfaction. As a secondary objective, the odds ratios (OR) for any intraoperative or postoperative complication, respectively, were computed for BMI ≥30 versus <30, and for uterus weight ≥500 g versus <500 g.

Results: A total of 545 patients were included in the study. The mean age of the patients was 49.9 ± 10.7 years. Of the included patients, 8.1% (n = 44) were nullipara, 19.3% (n = 105) had a BMI ≥30, 17.4% (n = 95) had a previous cesarean section, and 16.7% (n = 91) had other previous abdominal surgery. The median uterus weight was 148 g (interquartile range, IQR 86-299). The median surgical time was 65 minutes (IQR 48-91), and the median blood loss was 40 mL (IQR 25-90). Conversions to laparotomy occurred in 2% (n = 11), and reoperations occurred in 0.6% (n = 3) of the cases. The total intraoperative complication rate was 2.2% and the total postoperative complication rate was 8.4%. No significant differences in intraoperative and postoperative complications were found between BMI ≥30 and <30 and between uterus weight ≥500 and <500 g. Most of the patients (57.1%, n = 311) left the hospital the same day as the surgery. The 1-year follow-up after surgery showed that 90% of the patients were satisfied or very satisfied with the result.

Conclusions: The implementation of vNOTES hysterectomies in Sweden has been safe showing similar complication rates compared to studies of other minimally invasive hysterectomy techniques. Surgical time, intraoperative bleeding, and conversions were in analogy with previous observational vNOTES studies. The 1-year follow-up after surgery showed high patient satisfaction.

Introduction: Minimally invasive surgery is preferred over laparotomy due to shorter hospital stays, faster recovery, and reduced risk of complications. Despite these advantages, studies indicate an increased risk of vaginal cuff dehiscence (VCD) after laparoscopic and especially robotic-assisted total hysterectomy (RA-TLH). Over the past decades, the use of laparoscopic and robotic surgery has increased in the Western world, including the Nordic countries. It remains unclear who is at higher risk of VCD. This study aims to identify patient-related and surgical risk factors for VCD following RA-TLH.

Material and methods: A retrospective review of medical records of women who underwent RA-TLH at Trondheim University Hospital, Norway, from 2010 to 2021. Women experiencing VCD were identified and compared to women without VCD. Demographic and surgical data were compared between the groups using univariate and multivariate logistic regression analyses to identify risk factors for VCD.

Results: Out of 1549 eligible women, 684 (44.2%) consented to participate. Twenty-eight women (4.2%) were diagnosed with VCD at a median of 73 days (range 28-278) after surgery. Vaginal intercourse was identified as the triggering event in 23 (82%) women. Younger age, lower BMI, longer surgery duration, and higher uterine weight were associated with an increased risk of VCD in univariate analyses. Multivariate analysis showed that each unit increase in BMI reduced the odds, aOR 0.87 (95% CI 0.78-0.97), whereas each 100 g increase in uterine weight increased the odds, aOR 1.30 (95% CI 1.06-1.60).

Conclusions: VCD occurred in 4.2% of included women. Vaginal intercourse was the most common trigger of VCD. High BMI protected against VCD after RA-TLH. Women with a large uterus had an increased risk of VCD. Our findings underline the importance of preoperative counseling, discussing the advantages and risks of different surgical approaches according to each woman's risk factors.

Introduction: Term full dilatation cesarean delivery (FDCD) is associated with an increased risk of subsequent spontaneous preterm birth (sPTB). The impact of preterm FDCD on recurrent sPTB is unknown. We investigated the relationship between recurrent sPTB and the mode of prior sPTB.

Material and methods: This is a retrospective cohort study of singleton pregnant women attending two high-risk preterm birth surveillance clinics (University College London Hospital and St Thomas' Hospital London, UK), with one previous sPTB (24-36 + 6 weeks). Women were categorized according to their mode of birth in the index sPTB pregnancy: (1) preterm FDCD, (2) preterm vaginal birth and (3) preterm cesarean delivery at <10 cm cervical dilatation (CD < 10 cm). The primary outcome was recurrent sPTB <37 weeks of gestation. Secondary outcomes included sPTB <34 weeks, <28 weeks, spontaneous late miscarriage and short cervical length (≤25 mm). In a subgroup of women with preterm FDCD, CD scar characteristics were assessed during the second trimester of pregnancy using transvaginal ultrasound.

Results: Median gestation of prior sPTB was similar across all groups (32 weeks; p = 0.454). Recurrent sPTB <37 weeks was significantly more common in women with previous preterm FDCD, 38.1% (8/21) compared to vaginal birth, 15.1% (16/106) or CD < 10 cm, 13.8% (15/109); aOR 4.4 (95% CI 1.3-14.9; p = 0.023) and 5.1 (95% CI 1.6-16.5; p = 0.022), respectively. Recurrent sPTB <34 weeks was even higher in the previous preterm FDCD group, 23.8% (5/21) compared to vaginal birth 4.7% (5/106) or CD < 10 cm 8.3% (9/109); aOR 16.6 (95% CI 2.8-97.2; p = 0.016) and 5.7 (95% CI 1.4-23.1; p = 0.022), respectively. CD scar location was assessed in 15 women with preterm FDCD in one centre. Scar visualization was 87%, with 77% (10/13) of scars being located within the cervix or <5 mm above the internal cervical os.

Conclusions: Women undergoing FDCD following preterm labor have a significantly higher risk of recurrent sPTB at <37 and <34 weeks of gestation compared to women with previous preterm vaginal birth or CD prior to the second stage of labor. These findings suggest that preterm FDCD may further compromise cervical function. It is important that clinicians are aware of this increased risk of recurrent sPTB to guide patient counseling and management accordingly.

Introduction: Somatization disorders belong to a category of psychiatric conditions in which psychological distress and impairment are manifested as physical symptoms. Affected patients tend to utilize specialist healthcare services more frequently and have more emergency visits than those without somatization. From a gynecological perspective, it is of relevance to investigate whether any specific somatic symptoms are linked to previous experience of physical, psychological, or sexual violence. The study aimed to explore whether any specific symptoms could be associated with level of somatization among women consulting a gynecologist; whether experience of physical, psychological, or sexual violence could be associated with level of somatization; and whether experience of violence is associated with self-rated state of health.

Material and methods: A cross-sectional survey was conducted at three gynecological clinics in western Sweden between February and May 2024. A project-specific questionnaire was distributed to women who consulted the clinic and completed in the waiting room. The survey consisted of 13 items, including sociodemographic variables, reasons for the current gynecological consultation, self-rated health, history of physical, psychological or sexual violence, discomfort during gynecological examination, and somatic symptom severity. Data were analyzed using descriptive statistics, chi-square tests, ANOVA, and multivariable linear regression analyses.

Results: Of 2000 questionnaires distributed, 1766 were completed (response rate 88.3%). Among participants, 21.8% reported experience of sexual violence, 16.8% psychological violence, and 13.6% physical violence. Among those reporting any form of violence (n = 653), overlap was common: 236/653 (36.1%) had experienced only sexual violence, while 191/653 (29.2%) had experienced all three types. Somatic symptom severity was significantly associated with both sexual and psychological violence, but not physical violence. Clinical predictors of somatization included abdominal pain, dysmenorrhea, and multiple symptoms including pain. High somatic symptom severity was strongly associated with worse self-rated health. Somatic symptoms and specific consultation reasons, but not violence experiences, were significantly associated with self-rated health.

Conclusions: Somatization is common among women seeking gynecological care and is associated with a history of sexual and psychological violence. The findings underscore the importance of assessing underlying symptom patterns and the value of trauma-informed assessment to optimize patient management.

Introduction: Obstetric ultrasound is fundamental in prenatal care for gestational age (GA) estimation, fetal monitoring, and complication screening. However, access to quality ultrasound is limited in many low- and middle-income countries (LMICs), where nearly half of pregnant women receive no scans during pregnancy. Even in high-income countries, disparities in care persist. Recently, artificial intelligence (AI) applied to "blind" ultrasound sweeps-standardized transabdominal sweeps performed by minimally trained personnel-has emerged as a promising tool to improve access to diagnostic-quality prenatal ultrasound.

Material and methods: A systematic review following PRISMA guidelines was conducted. PubMed was searched through April 2025 using terms such as [blind sweep], [prenatal ultrasound], and [deep learning]. Studies were included if they assessed AI models applied to blind-sweep ultrasound for prenatal diagnostics. Fourteen studies (12 original, 2 reviews/meta-analyses) met eligibility. Data were extracted on study design, population, acquisition protocol, AI models, and diagnostic performance. Risk of bias was assessed using QUADAS-2.

Results: AI models demonstrated comparable or superior performance to expert sonographers in mid-trimester GA estimation, with mean absolute errors of 3-5 days. In a large multicenter study, AI outperformed traditional biometry (3.9 vs. 4.7 days error). Accuracy remained high even with minimally trained operators. AI also performed well in detecting breech presentation (AUC ~0.98), assessing amniotic fluid (Dice ~0.88; AFI accuracy ~91%), and segmenting fetal anatomy for biometry. Limitations included reduced accuracy in late pregnancy and limited validation in early gestation or anomaly detection.

Conclusions: AI-based blind sweep ultrasound holds transformative potential for global prenatal care, enabling scalable, low-cost diagnostics in LMICs and underserved settings. While promising, clinical adoption requires broader validation, improved interpretability, and integration into healthcare systems. With further development, this technology could significantly contribute to equitable prenatal diagnostics and reduced maternal-fetal morbidity worldwide.