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.
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.
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.
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.
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.
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.
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.
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.
We commend Lia et al. [1] for their innovative study introducing transperineal ultrasound (TPU) to measure the anteroposterior mid-pelvic diameter (AMD) in breech presentation. While the results are promising, several methodological issues undermine the validity of the predictive model and its clinical implications.
First, the multivariable logistic regression analysis risks severe overfitting. With only 17 events (intrapartum cesarean sections), including four variables—AMD, birthweight, head circumference, and obstetric conjugate (OC)—violates the standard of 10 events per variable. This low event-to-variable ratio (~4.25) likely inflates the effect size (adjusted odds ratio 0.25 per 1 cm AMD increase), rendering the model unreliable for clinical application, while established statistical guidelines recommend approximately 10 events per variable (EPV) to ensure the reliability of multivariable logistic regression models [2-5].
Second, the comparison of AMD's predictive performance (AUC 0.77) against traditional diameters such as the OC (AUC 0.60) is biased by study design. The OC was used as a criterion for offering vaginal birth (cutoff ≥ 12.0 cm), restricting its variability and artificially attenuating its predictive power. In contrast, AMD was not constrained, leading to an inequitable comparison that overstates AMD's superiority.
Furthermore, the clinical translation remains vague. Although Figure 5 suggests risk stratification by AMD quartiles, no actionable cutoff is proposed for patient counseling. The model's development without external validation or sample size justification limits its generalizability.
In conclusion, while TPU is a feasible tool, the study's statistical limitations necessitate cautious interpretation. We urge validation in a larger cohort with rigorous design to ensure robust, clinically relevant predictions before widespread adoption.
Medical Science and Technology Project of Zhejiang Province (No: 2024KY755).
We declare no competing interest.
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.
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.
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.
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.
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.
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).
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.
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.
Knowledge on women's pain and stress experiences during medical abortion is scarce and evidence mainly relies on retrospective reports, which are prone to recall bias. Hence, our objective was to study real-time self-reported pain and stress throughout the medical abortion process, their fluctuation over time, and to examine whether age, parity, gestational age, adverse childhood events (ACE), and contextual factors (e.g., analgesics intake, bleeding) were associated with pain and stress.
This one-group, single center, exploratory cohort study (conducted 2020–2023) used ecological momentary assessment (EMA). A population-based sample of women ≥18 years of age presenting for first trimester medical abortion at ≤9th week of gestation was approached after mifepristone intake. Sixty women aged 30.40 ± 6.61 years were included in this study. EMA commenced with mifepristone intake and entailed four prompts per day over a consecutive 7-day period. Main outcomes included self-reported pain and stress measured using visual analog scales (VAS). Secondary outcomes were clinical and demographic data as well as psychological measures. Data were analyzed using multilevel models.
Reported pain and stress varied not only throughout the abortion process but also between women, showing an increase on Day 3 (misoprostol intake) and a gradual decrease thereafter. While age, gestational age, and parity were not significantly related to pain, higher self-reported stress, more bleeding, more analgesic intake, and a higher number of ACEs were associated with higher pain levels. Higher stress levels, in turn, were associated with more ACEs, parity, analgesics intake, treatment-related events, and weekdays.
Our results highlight large interindividual variations in women's pain and stress experiences during first trimester medical abortion and thus emphasize the need for individualized counseling and pain treatment. Screening for ACEs, along with using event-based EMA protocols for future pain-management research, may promote tailored care.
Robot-assisted obstetric ultrasound is a method where the obstetrician in the hospital can control an ultrasound probe and assess biometric measurements and biophysical observations of a fetus, at a remote location. This two-aimed study evaluates the diagnostic accuracy of robot-assisted ultrasound compared to traditional ultrasound and explores patient experiences.
Forty-six middle-risk pregnant women in 2nd and 3rd trimester were recruited. Thirty women were recruited for an intra observer study to compare the quality of the robot-assisted obstetrical ultrasound and traditional obstetric ultrasound. Fifteen traditional ultrasound examinations and 15 robotic-assisted ultrasound examinations were performed and head circumference (HC), biparietal diameter (BPD), abdominal circumference (AC), femur length (FL), amniotic fluid index (AFI), Doppler in the umbilical arteria, and biophysical observations of the fetus were registered. Another 16 women were recruited to a mixed design study aiming to explore the women's experiences with the robot-assisted ultrasound method. These women completed a questionnaire of 20 questions about patient experience, using a 5-point Likert scale. Two of them also participated in qualitative interviews to provide deeper insights.
Biometric measurements showed excellent reliability (intraclass correlation coefficient 0.990–0.993) with acceptable limits of agreement. Twenty questions about patient experiences were asked and 94% of the women scored for highest level of satisfaction. Interviews revealed the value of avoiding long-distance travel when image quality and digital communication experiences are good.
Robot-assisted obstetric ultrasound is a reliable alternative to traditional ultrasound for middle-risk pregnancies in rural areas, offering high diagnostic accuracy and patient satisfaction. Most women would agree to a robotic ultrasound scan examination again. The patients' experiences are thus in line with the Norwegian governments' intention to use technology to secure equality in health care in rural areas.
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