Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries

OBJECTIVE

The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries.

DESIGN

Population-based cohort study.

SETTING AND POPULATION

A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS).

METHODS

In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries.

MAIN OUTCOME MEASURES

Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data.

RESULTS

A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia.

CONCLUSION

Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.

TWEETABLE ABSTRACT

An ultrasound assessment in women with placenta praevia or prior CS may double the awareness for AIP.

Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries

OBJECTIVE

The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries.

DESIGN

Population-based cohort study.

SETTING AND POPULATION

A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS).

METHODS

In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries.

MAIN OUTCOME MEASURES

Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data.

RESULTS

A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia.

CONCLUSION

Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.

TWEETABLE ABSTRACT

An ultrasound assessment in women with placenta praevia or prior CS may double the awareness for AIP.

Familial risk of obstetric anal sphincter injuries: registry-based cohort study

OBJECTIVE

To investigate the aggregation of obstetric anal sphincter injuries (OASIS) in relatives.

DESIGN

Population-based cohort study.

SETTING

The Medical Birth Registry of Norway from 1967 to 2008.

POPULATION

All singleton, vertex-presenting infants weighing 500 g or more. Through linkage by national identification numbers, 393 856 mother-daughter pairs, 264 675 mother-son pairs, 134 889 mothers whose sisters later became mothers, 132 742 fathers whose brothers later became fathers, 131 702 mothers whose brothers later became fathers and 88 557 fathers whose sisters later became mothers were provided.

METHODS

Comparison of women with and without a history of OASIS in their relatives.

MAIN OUTCOME MEASURE

Relative risk of OASIS after a previous OASIS in the family.

RESULTS

The risk of OASIS was increased if the woman's mother or sister had OASIS in a delivery (aRR 1.9, 95% CI 1.6-2.3; aRR 1.7, 95% CI 1.6-1.7, respectively). If OASIS occurred in one brother's partner at delivery, the risk of OASIS in the next brother's partner was modestly increased (aRR 1.2, 95% CI 1.1-1.4). If OASIS occurred in one sister at delivery, the risk of OASIS in the brother's partner was also increased a little (aRR 1.2, 95% CI 1.1-1.4). However, there was no excess occurrence in sisters whose brothers' partners had previously had OASIS (aRR 1.1, 95% CI 0.9-1.3).

CONCLUSIONS

There appears to be increased familial aggregation of OASIS. These risks are stronger through the maternal rather than the paternal line of transmission, suggesting a strong genetic role that shapes aggregation of OASIS within families. These observations must be cautiously interpreted because of bias from unmeasured confounding factors may have impacted the findings.

[From Problemata Aristotelis to the handbooks of Döderlein. The old book collection of the Rikshospitalet, a center of knowledge and a research tool]

The collection of old medical and scientific books from the National Hospital in Oslo is a valuable library for education and research. Most of the books are from the collections of the obstetric, paediatric and dermatological departments. The oldest date from the mid-sixteenth century, but the collection also reflects systematic purchases of medical literature after 1800. This library offers an exceptional opportunity in Norway for studying the development of medical knowledge and practice over two centuries.

[A "need not possible to describe by words"--physician refugees 1939-40]

From 1938 onwards, the predicament of Central European Jews was desperate. Norway was one of the most restrictive countries in terms of granting sanctuary to Jewish refugees; in 1939, however, director general of the Norwegian Board of Health Karl Evang (1902-81) proposed that entry permits be issued to a limited number of foreign physicians. This set off a fierce debate in newspaper, journals and medical associations. This article gives an account of that debate. The main arguments against allowing entry were fear of unemployment among Norwegian physicians and the contention that there was no need for foreign physicians in Norway. Anti-Semitic sentiments were hardly expressed. There was, however, almost no realization in Norway of the plight of the Jews, neither among the public at large nor in the medical profession. As it turned out, nine foreign physicians were allowed in, most of them from Czechoslovakia, four of them of professorial rank. Soon after the German occupation of Norway in 1940, Nazi authorities revoked their medical licenses.

[Løvseth's manoeuvre in breech presentation--"best and safest"]

During the first half of 20th century, the most important goal in obstetrics was to make vaginal deliveries safer. Two Norwegian gynaecologists put their mark on this development: Christian Kielland's (1871-1941) obstetric forceps and Jørgen Løvset's (1896-1981) manoeuvre in breech presentation. Løvset made several other contributions to Norwegian and international obstetrics, in particular a series of innovations. In his old age he advocated obstetrics as a form of art and underlined the importance of learning "what is necessary to be worthy of the name of obstetrician". He experienced the dramatic change in attitude to and frequency of caesarean section.

[With forceps all over the world--Christian Kielland and his forceps]

The history of the obstetric forceps is a colourful chapter in the history of medicine. Several hundred obstetric forceps have been described in detail, but most of them were minor modifications of the prototypes. However, the forceps invented by the Norwegian gynaecologist Christian Kielland (1871-1941) had a considerable impact upon the obstetric world during most of the 20th century. This ingenious instrument was demonstrated in Munich in 1915 and was gradually quite extensively used nearly all over the world. However, a great deal of controversy has surrounded his forceps, also in Norway.

["Now I am humble. Indeed." From Germany to Norway in 1934]

A huge refugee problem arose when the Nazis came to power in Germany in 1933. The most acute stages were just after 1933 and from the summer of 1938. This refugee drama involved all the western countries, including Norway. This paper describes the fate of the German gynaecologist Hans Saenger (1884-1943), professor in Munich, who in 1933 was dispelled by the Nazis because of his Jewish descent. He fled to Norway in 1934 and settled in Fredrikstad. However, the attitude in Norway to refugees in general and Jews in particular was hostile, mainly because of fear of unemployment. Prejudice and xenophobia were of importance, also in the medical profession.

[Obstetrics--a women's discipline for men]

In recent years there has been a considerable increase in the number of female gynaecologists in Norway. This contrasts sharply with the difficulties pioneering Norwegian female physicians had in entering this specialty. Three generations ago, leading Norwegian physicians argued against female gynaecologists. This article describes the controversy in 1914 when Dr. Louise Isachsen (1875-1932) claimed discrimination when she was not appointed senior registrar at the National Hospital's Midwifery Clinic. Her case was fiercely debated, not only in the medical profession, but also in newspapers and in Parliament. The clinic's director, Professor Kristian Brandt (1859-1932), found women unsuited for operative gynaecology and emergency obstetrics. We compare his arguments against female physicians with the requirements for Norwegian midwives, all female at the time. Brandt himself played a crucial role in formulating these requirements through his teaching and textbooks.

[The first cesarean section in Norway]

The first reported caesarean section in Norway was performed on 20 August 1843 by a general practitioner, Lars Thalian Backer (1812-84). The operation took place in Lardal, Vestfold County, on a 27 year old woman who had been in labour for six days. The outcome was disastrous; she was delivered of stillborn twins and died 2 1/2 days after the operation. In the 19th century, infection, bleeding and thromboembolic disease made caesarean section a dangerous operation, and only 26 such operations are known in Norway, most of them performed outside hospitals. The first caesarean section in Norway resulting in a living child was performed in 1849, but no mother survived the operation before 1890. We recapitulate the caesarean section of 1843; Dr Backer and his qualifications for operative obstetrics; and the state of instrumental and surgical obstetrics in Norway at that time.

[The introduction of obstetric forceps in Norway--a 250-year anniversary]

Johan Gottfried Erichsen (1713-68), born in Germany and chief medical officer in Bergen from 1747, was probably the first to perform a forceps delivery in Norway, on 14 February 1748. The mother, who had been in labour for five days, survived; the child, however, did not. The obstetric forceps had been a secret in the Chamberlen family and had become more widely known only a few decades earlier. Erichsen, who was the first man-midwife in Norway, had learned obstetrics in Paris by the younger Grégoire. He mastered both the techniques of internal version and forceps delivery. This article describes Erichsen's medical and obstetric background and his qualifications for operative obstetrics. He worked in the period when the obstetric forceps changed obstetrics, birth delivery became an arena also for men, and a part of medicine. Obstetrics was established as a science and physicians had a tool whereby also children could be saved during complicated delivery.

["An appropriate forceps"--150-year anniversary of Simpson's forceps]

Despite the increasing use of caesarean section and vacuum extraction, obstetric forceps is still in frequent use in obstetric wards. There has, in fact, been an increase due to more active management of births. More than 600 obstetric forceps have been described in detail, but only three of them are in use in Norway today: Simpson's and Kielland's forceps for vertex presentation and Piper's forceps for aftercoming head in breech presentation. This year it is 150 years since James Young Simpson (1811-70) of Edinburgh presented his forceps for the first time. Simpson's forceps has been the most widely used forceps in Norway over the last 120 years. This article describes James Young Simpson, his long forceps, and its use in Norwegian obstetrics.

Strenuous working conditions and birthweight, Norway 1989

OBJECTIVE

To examine whether strenuous working conditions in pregnancy are associated with reduced birthweight.

METHOD

Cross-sectional, population based study. Retrospective data collection by questionnaire to parturients in all maternity wards in Norway 16.10-26.11.89, completed before discharge from hospital, with response rate 87.2%. The study population consists of the 5388 women with singleton births, of whom 3321 were in paid work beyond the third month of pregnancy. Main outcome measures are prevalence of birthweight <2500 grams (LBW) and mean birthweight.

RESULTS

Strenuous working conditions increased risk of LBW, but only for nullipara, particularly non-smoking nullipara. Odds ratios with 95% confidence intervals for non-smoking nullipara, adjusted for age, education and income, were 0.3 (0.1,0.9) for influence on work pace, 2.8 (1.2,6.5) for exposure to heavy lifting and 2.2 (0.8,5.8) for twisting/bending. Four groups of occupations were defined according to exposure, solely based on reports from mothers with non-LBW children in order to avoid recall bias. Prevalence of LBW increased from 0.8% in the least exposed to 8.3% in the most exposed group. (Test for trend: p<0.05, after adjustment for age, education and income.) Strenuous working conditions had no independent effect on mean birthweight after adjustment for age, education, income and smoking.

CONCLUSION

Strenuous work increased the risk of LBW in nulliparae, particularly in non-smokers. Lack of influence on work pace was the strongest risk factor. The preventive effect of job modification in pregnancy may parallel smoking cessation.

[Sterilization of women. Waiting lists, surgical techniques and type of anesthesia]

The surgical and anaesthesiological techniques of tubal sterilization in Norway were studied by means of questionnaire. All hospitals returned the questionnaire. 94% of the operations were performed by gynaecologists, and in 99% of the cases by bipolar or endothermal laparoscopy. Local analgesia was used in one of the 60 hospitals. There were significant regional differences in sterilization rates and waiting time. We found no simple relation between sterilization technique and waiting lists.

[Ambulatory laparoscopic sterilization--should local analgesia and intravenous sedation replace general anesthesia? A comparative clinical trial]

A prospective, randomized study comprised 125 outpatient laparoscopic sterilization patients who had received either general anaesthesia or local anaesthesia together with intravenous sedation. The patients who had received local anaesthesia suffered significantly less postoperative pain and sore throat. Recovery and discharge were similar in the two groups, but those given a general anaesthetic were more drowsy in the evening on the day of operation. The time spent in the operating theatre was significantly shorter for the group given local anaesthesia, and the costs were lower. The majority of patients from both groups would prefer local anaesthesia and sedation for a similar procedure in the future. We conclude that local anaesthesia by intravenous sedation is the method of choice for laparoscopic sterilization.

Laparoscopic sterilization under local or general anesthesia? A randomized study

OBJECTIVE

To assess the safety, acceptability, and economy of local anesthesia and intravenous (IV) sedation versus short-term general anesthesia for laparoscopic sterilization.

METHODS

We randomly allocated 125 of 150 consecutively sterilized women to either local or general anesthesia. No women were excluded, but 25 chose not to participate. The women were interviewed before surgery, and they returned a standardized questionnaire after discharge from the hospital. All laparoscopic tubal sterilizations were performed by senior gynecologists. Midazolam was used as premedication. In the local-anesthesia group, lidocaine with adrenaline was infiltrated infraumbilically and bupivacaine was applied to each tube. Midazolam and alfentanil were used as IV sedation. In the general-anesthesia group, intubation anesthesia was accomplished with alfentanil and propofol; atracurium was used for muscle relaxation.

RESULTS

In the local-anesthesia group, operation time was shorter, perioperative discomfort was modest, and the costs of equipment were lower than in the general-anesthesia group. There was less postoperative abdominal pain and less need of analgesics, and the patients were more awake in the evening. The rise in heart rate and blood pressure were higher in the local-anesthesia group, and external oxygen was necessary to avoid apnea. Anesthetic surveillance was therefore mandatory.

CONCLUSIONS

Local analgesia was highly acceptable to the majority of patients as well as to the gynecologists. The operation time was less, postoperative recovery was quicker, and the women were less bothered by abdominal pain and sore throat. There was a substantial reduction in anesthesia costs. Anesthetic surveillance during surgery was necessary.

[Mortality and morbidity among infants with extremely low birth weight]

We reviewed outcomes in 65 infants with extremely low birth weight who were treated at our perinatal center from January 1981 through December 1989. Included in the study were infants whose gestational age was less than or equal to 26 weeks and whose birth weight was less than or equal to 750 grams. The outcomes were compared for three periods, 1981-83 (n = 16), 1984-86 (n = 20) and 1987-89 (n = 29). There was no significant difference in survival rate during the study period (19 vs 25 vs 31%). However, significantly more children now survive the first 24 hours of life.

Long-term regret among 216 sterilized women. A six-year follow-up investigation

Six years after tubal sterilization 16 of 208 women reported serious regret. The desire for another child in a new relationship was given as the main reason for later regret, although other causes were also reported. No association between age, parity, time or type of tubal sterilization and later regret was demonstrated. However, a greater proportion of regretters than of the remainder had been recommended the sterilization by a doctor at abortion application. The regretters had undergone more abortions before their sterilization, and the study revealed more unstable marriages with consequently less support from the spouse at sterilization in the regretting group. Post-sterilization regret is discussed within the framework of life events and social support.

Tubal sterilization. A historical review

During the 1970s there was a fivefold worldwide increase in the number of sterilizations. Sterilization has emerged in many countries as the most popular method of family planning for couples over 30 years of age. This paper reviews the developments in tubal sterilization, with special emphasis on the early years and the development of laparoscopic techniques.

The attitudes of sterilized women to contraceptive sterilization

Six years after their sterilization, 206 of 216 consecutively sterilized women were interviewed. Included in the semistructured interview was a series of questions about their more general attitudes to tubal sterilization. Half of the women considered the early thirties the appropriate age for contraceptive sterilization. Sixty-four women argued for male sterilization, 59 for female. The protagonists for vasectomy were younger. Twenty-seven women said contraceptive sterilization should not be more widespread, 38 believed postoperative regret was common. The abortion situation was considered inappropriate in the discussion of sterilization by 66 women; 131 found it sensible. While 84 women considered the new, liberal sterilization legislation an improvement, 110 did not agree, mainly because they considered the age limit of 25 years too low.

The social and gynaecological background of 218 sterilized women

This is the first part of a longitudinal follow-up study of 218 consecutively sterilized women. The operations were performed at the Gynaecological Department of Akershus Central Hospital during the period May 22nd 1973 to February 1, 1974. The mean age of the women was 33.5 years, their mean parity 2.8. They could not be distinguished from the women of the same age in the county at large with regard to incomes, education or housing conditions. The usage of contraception was widespread, but not consistent. Fifty-eight per cent of the operations were performed postabortion, 69% of the women had at least one, 21% at least two induced abortions before the sterilization. Family planning was the predominant stated motive for sterilization, and the present study indicates that the sterilization legislation of 1934 was outdated some years before it was succeeded by a new law. Sterilization was suggested by the doctor in 40%, at abortion application in 30%.

Complications and short-term consequences of tubal sterilization. A personal three- and twelve-month follow-up investigation

The aim of the present study was to investigate the short-term complications and consequences of 216 consecutive female sterilizations. Information was obtained from 211 women (98%) within the first postoperative year. There was one failure (Pomeroy), three skin burns, a vesical lesion and problems with the induction of anesthesia in 2 cases. Thirty-nine women were bothered by minor complaints for 3 months or more, in most cases by discomfort of the laparotomy scar. The impact on postoperative marital life was mainly positive. Twenty-three women expressed doubts whether the sterilization had been sensible, 10 expressed real regret at at least one interview. At one year, 4 stated serious regret. One year after surgery, 68% had told friends about the sterilization; these women were younger than the remainder. Forty-six percent said they would have preferred an earlier operation.

The social and gynecological long-term consequences of tubal sterilization. A personal six-year follow-up investigation

The long-term consequences and complications of tubal sterilization were studied. Six years after surgery, information was obtained from 208 of 216 women. Five had been pregnant. Eight had been bothered by their scars for 2 years or more. The majority reported improved conjugal relations and a positive impact on marriage. Eighty-five percent had told others about the sterilization; the frankness was more common in the younger age groups. Although most women were satisfied, 6% would have preferred the sterilization undone. In 10% of the couples, at least one of the partners held that view. The most common cause for regret was the desire for more children, in most cases with a new spouse. Regret was not correlated to the woman's age, parity or social group. Regret was recorded with significant predominance when the sterilization had been suggested by a doctor at abortion application. In a controlled comparison between Pomeroy laparotomy and laparoscopic electrocoagulation, no differences in postoperative bleeding patterns were found. The present study indicates that tubal sterilization is not a major cause of subsequent menstrual irregularities.

Tubal sterilization. A prospective long term investigation of 218 sterilized women

The present study is a long-term investigation of 218 consecutively sterilized women in Akershus County, Norway. The operations were performed in 1973-74, when the access to sterilization was regulated by a legislation from 1934. The women were interviewed personally, and a clinical examination was performed before sterilization, at discharge from hospital, three months, one and six years later. At each occasion the participation was about 95%, and only one woman was lost to follow-up. The women in this series lived in stable social conditions, their average age was 33.7, their parity 2.8. They were not socially distinguishable from women of the same age in the county at large, but there were important socially and age related differences within the series. Their contraceptive usage was widespread, but inconsistent. Family planning was the all-dominant motive. Forty per cent of the women had been suggested the sterilization by a doctor, 30% at abortion application. The operations were performed as laparoscopic electrocoagulation of the tubes or as a Pomeroy resection. Five pregnancies were recognized in the study period, four of these in the laparoscopy group. There were few serious complications, but 20% had a diversity of complaints at the three month interview. At six years seven women had complaints attributed to the operation. The large majority of the series was satisfied with the sterilization. Almost half the women would have preferred an even earlier operation, and six years after the sterilization 85% of the women had told friends about it, and 71% of these had directly recommended sterilization to someone. Six years after the sterilization 74% said the operation should be more widespread, 69% believed postoperative regret was uncommon, and the impact on postoperative marital life was mainly positive. However, during the study period, 18% of the women had experienced regret, ambivalence or periodic depression because of their sterilization. The rate of, and reasons for regret varied with time. The rate increased; at six years 6% of the women would have preferred the sterilization undone, and in 10% of the couples at least one of the partners held that view. At one year, the primary reason for regret was a feeling of having been persuaded by the doctor at abortion application. Six years after the sterilization the desire for a child with a new spouse was the principle reason. There was no association between regret and age or parity at operation.(ABSTRACT TRUNCATED AT 400 WORDS)