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  • 1.
    Akhter, Tansim
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Wikström, Anna-Karin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Chemistry.
    Naessen, Tord
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Changes in the Artery Wall Layer Dimensions in Women with Preeclampsia: an investigation using non-invasive high frequency ultrasound2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, no S159, p. 28-28Article in journal (Other academic)
    Abstract [en]

    Background:

    Preeclampsia (PE) is associated with increased risk for cardiovascular disease later in life. Whether, the artery wall layer dimensions differ between PE and normal pregnancy is unclear. The aim of this study was to estimate if women with PE have different common carotid artery wall layer dimensions than women with normal pregnancy, both during pregnancy and about one year postpartum.

    Methods:

    By using high-frequency (22MHz) ultrasound (Collagenoson, Meudt, Germany) separate estimates of the common carotid artery intima and media layers were obtained and the I/M ratio was calculated in women with PE (n=55 during pregnancy and n=48 at postpartum) and with normal pregnancy (n=65 during pregnancy and n=59 at postpartum). Thick intima, thin media and a high intima/media ratio are signs of less healthy artery wall and vice versa.

    Results:

    In women with PE, the intima was thicker (0.18 } 0.03 vs. 0.11 } 0.02; p < .001), the media was thinner (0.47 } 0.12 vs. 0.55 } 0.14; p = .001) and the I/M ratio was higher (0.41 } 0.14 vs. 0.20 } 0.05; p < .001) compared to women with normal pregnancy. Further, for changes from pregnancy to postpartum, both for PE and normal pregnancy, the intima and the I/M ratio had improved but still significantly higher in women with PE than in women with normal pregnancy.

    Conclusion:

    In women with PE, we found a thicker intima, thinner media and a higher I/M ratio compared to women with normal pregnancy, indicating a more negatively affected artery wall layer dimensions. Persisting negative effects of PE on artery wall at postpartum, despite improvement of artery wall layers compared to values during pregnancy, indicates a permanent damage of the vascular system in this group of women.

  • 2.
    Amini, Hashem
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Antonsson, Per
    Papadogiannakis, Nikos
    Ericson, Katharina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Genetics and Pathology.
    Pilo, Christina
    Eriksson, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Genetics and Pathology.
    Westgren, Magnus
    Axelsson, Ove
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Comparison of ultrasound and autopsy findings in pregnancies terminated due to fetal anomalies2006In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 85, no 10, p. 1208-1216Article in journal (Refereed)
    Abstract [en]

    Objective. To compare antenatal diagnoses with autopsy findings in pregnancies terminated after ultrasound detection of fetal anomalies. A second aim was to study the quality of antenatal fetal diagnosis over time. Design. Retrospective, multicenter study over two consecutive six-year periods in Uppsala and Stockholm. Setting. Cases were identified through fetal autopsy reports. Subjects. Three hundred and twenty-eight fetuses from pregnancies terminated between 1992 and 2003 because of ultrasonographically diagnosed anomalies. Main outcome measures. The findings at the last ultrasound examination were compared with the autopsy reports. Results. In 299 cases (91.2%) ultrasound findings either exactly matched or were essentially similar to the autopsy findings. In 23 cases (7%) ultrasound findings were not confirmed at autopsy, but the postnatal findings were at least as severe as the antenatal ones. In six cases (1.8%) termination was performed for an anomaly which proved to be less severe than was predicted by ultrasound. The number of such cases was the same in both six-year periods, while the total number of cases increased from 113 in the first to 215 in the second period. Fetal examination provided further diagnostic information in 47% of the cases. In 10% a syndrome was disclosed. Conclusion. Termination of pregnancy was not always based on a correct antenatal diagnosis. All fetuses but one from terminated pregnancies had evident anomalies. In six cases (1.8%) the decision to terminate was based on suboptimal prognostic and diagnostic information. Fetal autopsy by an experienced perinatal pathologist is essential to provide a definitive diagnosis.

  • 3.
    Amini, Hashem
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Axelsson, Ove
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Ollars, Birgitta
    Swedish Birth Defects Registry, National Board of Health and Welfare, Stockholm, Sweden.
    Annerén, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Genetics and Pathology.
    The Swedish Birth Defects Registry: ascertainment and incidence of spina bifida and cleft lip/palate2009In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 88, no 6, p. 654-659Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To assess the ascertainment of spina bifida and cleft lip/palate (CLP) in newborns and in fetuses from terminated pregnancies (ToPs) in the Swedish Birth Defects Registry (BDR) and to estimate the true incidences of these two anomalies. DESIGN: Retrospective register study. SETTING: Center for Epidemiology at the Swedish National Board of Health and Welfare, and Uppsala University Hospital. POPULATION: Newborns and fetuses from ToPs with spina bifida (1999-2004) and CLP (1999-2002) in Sweden. METHODS: Data from four registries/sources were used to estimate ascertainment in BDR and incidences of spina bifida and CLP. Main outcome measure: Ascertainment, under-ascertainment, and true incidence. RESULTS: For newborns, under-ascertainment of spina bifida and CLP were 6 and 13%, respectively, in BDR after record linkage with the Medical Birth Registry. Ascertainment of cleft palate increased when accompanied by cleft lip. The under-ascertainment of spina bifida in ToPs after 18 gestational weeks was 27%. Ascertainment of CLP in all ToPs and of spina bifida in ToPs before the 18th gestational week could not be estimated. The majority (109/155, 70%) of ToPs with spina bifida occurred before the 18th week. The estimated incidence of spina bifida per 10,000 births was 6.1 (2.4 newborns and 3.7 ToPs) and of CLP 20.1 (18.9 newborns and 1.2 ToPs). CONCLUSION: The ascertainments are relatively high for newborns in BDR, but lower or unknown for ToPs, which has an impact on the surveillance of spina bifida in view of the high proportion of ToPs.

  • 4.
    Amini, Hashem
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Axelsson, Ove
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Raiend, Marie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Oncology, Radiology and Clinical Immunology, Radiology.
    Wikström, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Oncology, Radiology and Clinical Immunology, Radiology.
    The Clinical Impact of Fetal Magnetic Resonance Imaging on Management of CNS Anomalies in the Second Trimester of Pregnancy2010In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 89, no 12, p. 20p. 1571-1581Article in journal (Refereed)
    Abstract [en]

    Objectives: To evaluate the additional information of second trimester magnetic resonance imaging (MRI) compared to ultrasound in fetuses with identified or suspected CNS anomalies and to study the clinical impact of the information on pregnancy management.

    Design: Prospective study during 2004-2007. The fetal MRI examination was planned to be performed within three days after the ultrasound.

    Setting: Uppsala University hospital.    

    Subjects: Twenty-nine pregnant women where second trimester ultrasound identified or suspected fetal CNS anomalies.

    Main outcome measures: Evaluation of the additional information gained from MRI and the consequence it had on pregnancy management.

    Results: The mean interval between ultrasound and MRI was 1.6 days (range 0 –7). In 18 fetuses (62 %)  MRI verified the ultrasound diagnosis but provided no additional information, while in 8 (28 %) MRI gave additional information without changing the management. In 3 (10 %), MRI provided additional information that changed the management of the pregnancy. Two of these women were obese.

    Conclusions: Fetal MRI in the second trimester might be a clinically valuable adjunct to ultrasound for the evaluation of CNS anomalies, especially when ultrasound is inconclusive due to maternal obesity.

     

  • 5.
    Amini, Hashem
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Wikström, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
    Ahlström, Håkan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
    Axelsson, Ove
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Second trimester fetal magnetic resonance imaging improves diagnosis of non-central nervous system anomalies2011In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 90, no 4, p. 380-389Article in journal (Refereed)
    Abstract [en]

    Objectives. To evaluate the additional information of second trimester magnetic resonance imaging (MRI) compared to ultrasound in fetuses with identified or suspected non-CNS anomalies and to study the clinical impact of the MRI information on pregnancy management. Design. Prospective study during 2003-2007. The fetal MRI examination was planned to be performed within three days after the ultrasound. Setting. Uppsala University hospital. Material and methods. Sixty-three women, where the second trimester ultrasound identified or raised suspicion of fetal anomalies were included. Ultrasound was compared to MRI in relation to the final diagnosis, which was based on the assessment of all available data including post-partum clinical follow-up and autopsy results. Main outcome measures. Evaluation of the additional information gained from MRI and the consequences it had on pregnancy management. Results. The mean interval between ultrasound and MRI was 2.6 days (range 0-15). In 42 (67%) cases MRI was performed within three days. All MRI examinations were assessable. In 43 (68%) fetuses MRI provided no additional information, in 17 (27%) MRI added information without changing the management and in three (5%) MRI provided additional information which changed the management. All these three cases had oligohydramnios. In all six cases of diaphragmatic hernia MRI provided additional information. Conclusions. Fetal MRI of non-CNS anomalies in the second trimester seems to be a valuable adjunct to ultrasound diagnosis of non-CNS anomalies, especially in cases of oligohydramnios and diaphragmatic hernia.

  • 6. Andersson, Liselott
    et al.
    Sundström-Poromaa, Inger
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Wulff, Marianne
    Åström, Monica
    Bixo, Marie
    Depression and anxiety during pregnancy and six months postpartum: a follow-up study2006In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 85, no 8, p. 937-944Article in journal (Refereed)
    Abstract [en]

    Aims. To investigate the relationship between antenatal and postpartum depression and anxiety and to explore associated maternal characteristics. Methods. From a population-based sample of 1,555 women attending two obstetric clinics in Sweden, all women with an antenatal psychiatric diagnosis (n = 220) and a random selection of healthy women (n = 500) were contacted for a second assessment three to six months postpartum. The Primary Care Evaluation of Mental Disorders was used for evaluation on both occasions. Results. Fewer cases of depressive and/or anxiety disorders were prevalent postpartum compared with the second trimester screening. Depression and/or anxiety were prevalent in 16.5% of postpartal women versus 29.2% of pregnant women. There was a significant shift from a majority of subthreshold diagnoses during pregnancy to full Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnoses during the postpartum period. A history of previous psychiatric disorder, living single, and obesity were significantly associated with a new-onset postpartum psychiatric disorder. The absence of a previous psychiatric disorder was significantly associated with a postpartum recovery of depression or anxiety. Conclusions. Depression and anxiety appear to be less common postpartum than during pregnancy.

  • 7.
    Andersson, Ola
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
    Hellström-Westas, Lena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
    Andersson, Dan
    Clausen, Jesper
    Domellöf, Magnus
    Effects of delayed compared with early umbilical cord clamping on maternal postpartum hemorrhage and cord blood gas sampling: a randomized trial2013In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 92, no 5, p. 567-574Article in journal (Refereed)
    Abstract [en]

    Objective

    To investigate the effect of delayed cord clamping (DCC) compared with early cord clamping (ECC) on maternal postpartum hemorrhage (PPH) and umbilical cord blood gas sampling.

    Design

    Secondary analysis of a parallel-group, single-center, randomized controlled trial.

    Setting

    Swedish county hospital.

    Population

    382 term deliveries after a low-risk pregnancy.

    Methods

    Deliveries were randomized to DCC (≥180 seconds, n = 193) or ECC (≤10 seconds, n = 189). Maternal blood loss was estimated by the midwife. Samples for blood gas analysis were taken from one umbilical artery and the umbilical vein, from the pulsating unclamped cord in the DCC group and from the double-clamped cord in the ECC group. Samples were classified as valid when the arterial-venous difference was -0.02 or less for pH and 0.5 kPa or more for pCO2.

    Main outcome measures

    PPH and proportion of valid blood gas samples.

    Results

    The differences between the DCC and ECC groups with regard to PPH (1.2%, p = 0.8) and severe PPH (-2.7%, p = 0.3) were small and non-significant. The proportion of valid blood gas samples was similar between the DCC (67%, n = 130) and ECC (74%, n = 139) groups, with 6% (95% confidence interval: -4%-16%, p = 0.2) fewer valid samples after DCC.

    Conclusions

    Delayed cord clamping, compared with early, did not have a significant effect on maternal postpartum hemorrhage or on the proportion of valid blood gas samples. We conclude that delayed cord clamping is a feasible method from an obstetric perspective.

  • 8. Andrae, B.
    et al.
    Eriksson, L. G.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Oncology, Radiology and Clinical Immunology, Radiology.
    Skoog, G.
    Anti-shock trousers (MAST) and transcatheter embolization in the management of massive obstetrics hemorrhage: A report of two cases1999In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 78, no 8, p. 740-741Article in journal (Refereed)
  • 9.
    Arnadottir, Ragnheidur
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Hudecova, Miriam
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Stavreus-Evers, Anneli
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Kunovac-Kallak, Theodora
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Poromaa, Inger Sundstrom
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Olovsson, Matts
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Steroid hormone receptor expression, proliferative activity and microvessel density in the endometrium of women with polycystic ovary syndrome2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, p. 64-64Article in journal (Other academic)
  • 10.
    Belachew, Johanna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Axelsson, Ove
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD). Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Eurenius, Karin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Mulic-Lutvica, Ajlana
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Three-dimensional ultrasound does not improve diagnosis of retained placental tissue compared to two-dimensional ultrasound2015In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 94, no 1, p. 112-116Article in journal (Refereed)
    Abstract [en]

    The study objective was to improve ultrasonic diagnosis of retained placental tissue by measuring the volume of the uterine body and cavity using three-dimensional (3D) ultrasound. Twenty-five women who were to undergo surgical curettage due to suspected retained placental tissue were included. The volume of the uterine body and cavity was measured using the VOCAL imaging program. Twenty-one women had retained placental tissue histologically verified. Three of these had uterine volumes exceeding the largest volume observed in the normal puerperium. Seventeen of the 21 women had a uterine cavity volume exceeding the largest volume observed in the normal puerperium. In all 14 cases examined 28 days or more after delivery the cavity volume exceeded the largest volume observed in the normal puerperium. A large cavity volume estimated with 3D ultrasound is indicative of retained placental tissue. However, 3D ultrasound adds little or no diagnostic power compared to 2D ultrasound.

  • 11.
    Belachew, Johanna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Axelsson, Ove
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i D län (CKFD).
    Mulic-Lutvica, Ajlana
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Eurenius, Karin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Longitudinal study of the uterine body and cavity with three-dimensional ultrasonography in the puerperium2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, no 10, p. 1184-1190Article in journal (Refereed)
    Abstract [en]

    Objective.

    To describe uterine involution in the puerperium with three-dimensional ultrasound.

    Design.

    Prospective, longitudinal study.

    Setting.

    Fetal medicine unit, department of obstetrics and gynecology, university referral hospital, Uppsala, Sweden.

    Population.

    Fifty women with uncomplicated deliveries and puerperium between February 2009 and February 2010.

    Methods.

    Three-dimensional ultrasound was used to measure the uterine body and cavity volumes. The volume data set was analysed using virtual organ computer-aided analysis (VOCAL) with a 30 degree rotation step. Measurements were performed transabdominally on days 1, 7 and 14 and transvaginally on days 28 and 56 postpartum. Parity, gestational age, birthweight, smoking, breastfeeding and blood loss were recorded.

    Main outcome measures.

    Uterine body and cavity volumes. Results. Median uterine body volume was 756 cm3 on day 1, 440 cm3 on day 7, 253 cm3 on day 14, 125 cm3 on day 28 and 68 cm3 on day 56. Median cavity volume was 22 cm3 on day 1, 18 cm3 on day 7, 6 cm3 on day 14, 1 cm3 on day 28 and not measurable on day 56. The interindividual variation of uterine body and cavity volumes was most pronounced on day 1 and decreased throughout the observation period. Intrauterine content was found in 36% of the women on day 1, 95% on day 7, 87% on day 14 and 28% on day 28.

    Conclusions.

    Three-dimensional ultrasound is a non-invasive tool suitable for measurement of the uterine body and cavity volumes during the puerperium. The volumes decreased in a similar pattern in the study population.

  • 12.
    Bergendal, Annica
    et al.
    Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden.
    Odlind, Viveca
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Persson, Ingemar
    Medical Products Agency, Uppsala, Sweden.
    Kieler, Helle
    Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden.
    Limited knowledge on progestogen-only contraception and risk of venous thromboembolism2009In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 88, no 3, p. 261-266Article, review/survey (Refereed)
    Abstract [en]

    Objective. To assess the current knowledge concerning progestogen-only contraception (POC) and risks of venous thromboembolism (VTE). Design and setting. Systematic review of the literature on observational and analytical studies reporting risk estimates for VTE in women exposed to POCs. Methods and main outcome measures. We performed a computerized literature search in the Pub Med, Embase, and the Cochrane Library for studies published between 1966 and February 13, 2008. Based on the evaluated studies we calculated an overall risk estimate for VTE in association with POC. Results. Four case-control studies and one cohort study were included. Of the case-control studies, three reported an increased risk and one a decreased risk of VTE. The cohort study found divergent results depending on the type of statistical analysis used. None of the results was statistically significant. The overall odds ratio for POC-associated VTE in the four case-control studies was 1.45 (95% CI=0.92-2.26). Conclusions. The risk of VTE associated with use of POCs is poorly investigated. The slightly elevated overall risk estimate might suggest an association between POC and an increased risk for VTE. The results must, however, be interpreted with caution due to the possibility of residual confounding. Well-designed studies with sufficient statistical power to evaluate risks of VTE with POC are warranted.

  • 13. Berglund, Anna
    et al.
    Lefevre-Cholay, Helene
    Bacci, Alberta
    Blyumina, Anna
    Lindmark, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Successful implementation of evidence-based routines in Ukrainian maternities2010In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 89, no 2, p. 230-237Article in journal (Refereed)
    Abstract [en]

    Objective. To describe the process of change and assess compliance and effect on maternal and infant outcome when the WHO package Effective Perinatal Care (EPC) was implemented at maternities in Ukraine. Design. Intervention study comparing outcomes before and during 2.5 years after training. Setting. Three maternities in Donetsk, Lutsk and Lviv 2003-2006. Population. Baseline data were collected for 652, 742 and 302 deliveries and 420, 381 and 135 infants, respectively, in Donetsk, Lutsk and Lviv. Follow-up data included 4,561, 9,865 and 7,227 deliveries and 3,829, 8,658 and 6,401 infants. Methods. Staff training on evidence-based guideline. Main outcome measures. Interventions during labor, maternal outcomes and hypothermia in the infants. Results: EPC procedures were successfully implemented and adherence to the protocols was excellent. For most variables, the change occurred during the first three months but was well sustained. The use of partogram increased fourfold in Donetsk and from 0% to 60% in Lviv. Induction and augmentation of labor decreased to less than 1% and less than 5%, respectively. Cesarean section rate dropped significantly in two of the maternities. The proportion of hypothermic infants decreased from 60% (Donetsk), 85% (Lutsk) and 77% (Lviv) to 1% in all three maternities during the first three months and was stable throughout the study period. Admission to Neonatal Intensive Care Unit decreased significantly in two of the maternities and there was no effect on early neonatal mortality. Conclusions: The process of education and change was well anchored in the organization, and implementation of new procedures was quick and successful.

  • 14.
    Berglund, Anna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Lindberg, Marianne
    Nyström, Lennarth
    Lindmark, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Combining the perspectives of midwives and doctors improves risk assessment early pregnancy2007In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 86, no 2, p. 177-184Article in journal (Refereed)
    Abstract [en]

    Background. Traditionally, risk identification in early pregnancy in Swedish antenatal care [ANC] is performed by the midwife at booking, and confirmed by the doctor at a routine visit in early pregnancy, but this extra visit has been questioned. This study compared the risk assessment by the two professions. Methods. In a cluster randomised trial, a planning conference, where midwives reported new mothers to a doctor, replaced the routine consultation with the doctor. Ten ANC-clinics with the new program (942 mothers) were compared to 10 clinics with standard care (758 mothers). Risk factors were registered independently by midwives and doctors. Degree of agreement in risk identification between midwives and doctors was estimated by the kappa coefficient. Results. The degree of agreement in risk registration was good for previous pregnancy complications (κ=0.62; CI: 0.55-0.68), and recommendations for doctor's consultation (κ=0.67; CI: 0.62-0.72); fair for social problems (κ=0.29; CI: 0.03-0.55), and poor for registration of symptoms and problems in index pregnancy (κ=0.09; CI: 0.03-0.21) and psychosocial aspects, such as anxiety (κ=0.09; CI: 0.03-0.21). Significantly more risk factors were registered in the study group. Conclusions: Replacing the routine consultation with the doctor early in pregnancy with a planning conference had no negative impact on risk identification. The results support that the different perspectives of the two professions in combination are important for the safety of surveillance and the psychosocial support expected from antenatal care.

  • 15.
    Bergman, Eva
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Axelsson, Ove
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Kieler, Helle
    Centre for Pharmacoepidemiology (CPE), KArolinska Institutet, Solna, Sweden.
    Sonesson, Christian
    E Street Statistics Mölndal, Sweden.
    Petzold, Max
    Nordic School of Public Health, Göteborg, Sweden.
    Relative growth estimated from self-administered symphysis fundal measurements2011In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 90, no 2, p. 179-185Article in journal (Refereed)
    Abstract [en]

    Objective. To establish absolute-and relative-growth reference curves for the detection of intrauterine growth restriction from weekly self-administered symphysis-fundus (SF) measurements and to assess the influence of fetal sex, maternal obesity and parity. Design. Prospective longitudinal study. Setting. Pregnant women from six primary antenatal care centres. Population. Three hundred women with singleton ultrasound dated pregnancies. Methods. Weekly self-administered SF measurements from gestational week 25 until delivery were obtained. A linear mixed longitudinal model was used to estimate the absolute SF growth using the natural logarithm (lnSF). Relative lnSF growth was calculated as the lnSF measurement in one gestational week subtracted by the lnSF measurement in the previous gestational week. The influence of fetal sex, maternal obesity and parity was assessed in regression models and by a graphical display. Main Outcome Measures. Absolute lnSF and relative lnSF growth curves and influence of fetal sex, maternal obesity and parity on these. Results. SF measurements from 191 women were used to establish an SF-growth reference. The absolute lnSF growth was influenced by maternal obesity, and for fetal sex and parity, borderline significance was recorded; while there was no evidence that the relative lnSF growth could depend on these variables. Conclusions. Weekly self-administered SF measurements can be obtained and used to estimate SF growth. Relative growth of the lnSF height seems to be independent of fetal sex, maternal obesity and parity.

  • 16.
    Bergman, Eva
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Axelsson, Ove
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Petzold, Max
    Nordic School of Public Health, Gothenburg.
    Sonesson, Christian
    E Street Statistics, Mölndal.
    Kieler, Helle
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Self-administered symphysis-fundus measurements analyzed with a novel statistical method for detection of intrauterine growth restriction: a clinical evaluation2011In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 90, no 8, p. 890-896Article in journal (Refereed)
    Abstract [en]

    Objective. To assess the ability of self-administered symphysis fundus measurements used with the Shiryaev-Roberts statistical method (SR method) to identify growth-restricted (IUGR) fetuses and compare it with the traditional SF method (symphysis fundus measurements used with a population-based reference curve). Design. Longitudinal study. Setting. Pregnant women attending primary antenatal care centres. Population. From a population of 1 888 women with singleton ultrasound-dated pregnancies, we analyzed data from 1 122 women. Methods. Weekly self-administered SF measurements from gestational week 25 until delivery were analyzed according to the SR method. Neonatal morbidity and small for gestational age (SGA) were used as proxies for IUGR. Small for gestational age was defined as a birthweight less than two standard deviations (SD) and <10th percentile. We assessed the sensitivity of the SR and the SF methods to detect neonatal morbidity and SGA. Main Outcome Measures. Birth-related mortality, respiratory distress, hypoglycemia, Apgar score <= 6 at five minutes, pH <= 7.00 in the umbilical artery, neonatal care, preterm delivery, operative delivery for fetal distress and SGA. Results. For the SR method, the sensitivity for neonatal morbidity was between 6.0 and 36.4%, for SGA <2SD 36.8%, and for SGA <10th percentile 20.9%. The SF method had a sensitivity between 6.0 and 13.8% for neonatal morbidity, 52.3% for SGA <2SD and 28.6% for SGA <10th percentile. Conclusions. The SR and the SF methods had low sensitivities for neonatal morbidity.

  • 17.
    Bergman, Eva
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Kieler, Helle
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Petzold, Max G.
    Nordic School of Public Health, Göteborg.
    Sonesson, Christian
    Statistical Research Unit, Göteborg University.
    Axelsson, Ove
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Symphysis-fundus measurements for detection of small for gestational age pregnancies2006In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 85, no 4, p. 407-12Article in journal (Refereed)
    Abstract [en]

    Background. In Sweden measurements of the symphysis-fundus (SF) distance are used to detect small for gestational age (SGA) pregnancies. The aim of this study was to evaluate the efficiency of Swedish ultrasound-based SF reference curves in detecting SGA pregnancies. Methods. To assess the sensitivity for detection of SGA pregnancies we performed a case-control study. Through the Swedish Medical Birth Register we identified all singelton SGA infants born in Uppsala 1993-1997 and randomly recruited non-SGA singelton as controls. We included 169 term and 73 preterm SGA cases and 296 controls, all born at term. The reference curves constructed from Steingrimsdottir (S curve) and Kieler (K curve) were evaluated. Gestational age at first alarm in the preterm SGA group was recorded. Results. In term pregnancies the S curve showed a sensitivity of 32 % and a specificity of 90 % at a cut-off at -2 SDs. The corresponding values for the K curve were 51 % and 83 %, respectively. In preterm pregnancies the sensitivity of the S curve was 49 % and for the K curve 58 %. The first alarm below -2 SD was noted before 32 weeks in 37 % with the S curve and 43 % with the K curve for preterm pregnancies. Conclusions. Both tested Swedish reference curves had low sensitivity for term SGA pregnancies. Sensitivity was higher for the preterm group and SF measurements seem to be better for detecting the most severe cases of SGA.

  • 18.
    Bergman, Eva
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Kieler, Helle
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Petzold, Max
    Sonesson, Christian
    Axelsson, Ove
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Self-administered measurement of symphysis-fundus heights2007In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 86, no 6, p. 671-677Article in journal (Refereed)
    Abstract [en]

    Background. Antenatal identification of infants small for gestational age (SGA) improves their perinatal outcome. Repeated measurements of the symphysis-fundus (SF) heights performed by midwives is the most widespread screening method for detection of SGA. However the insufficiency of this method necessitates improved practices. Earlier start and more frequent SF measurements, which could be acomplished by self-administered measurements, might improve the ability to detect deviant growth. The present study was set up to evaluate wether pregnant wome can reliable perform SF measurements by themself. Method. Forty healthy women with singelton and ultrasound-dated pregancies from 2 antenatal clinics in Uppsala, Sweden, were asked to perform 4 consecutive SF measureemnts once a week, from 20 to 25 weeks of gestation until delivery. The self-administered SF measurements were recorded and systematically compared with midwives' SF measurements. Results. Thirty-three pregnant women performed self-administered SF measurements over a 14-week period (range 1-21). The SF curves constructed from self-admiinistered SF measurements had the same shape as previously constructed population-based reference curves. The variance for self-admiinistered SF measurements was higher than that of the midwives. Conclusions. Pregnant women are capable of measuring SF heights by themselves, but with a higher individual variance than midwives. Repeated measurements at each occasion can compensate for the higher variance. The main advantage of self-administered SF measurements is the opportunity to follow fetal growth earlier and more frequently.

  • 19. Bergsjö, Per
    et al.
    Bakketeig, Leiv S.
    Lindmark, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Maternal smoking does not affect fetal size as measured in the mid-second trimester2007In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 86, no 2, p. 156-160Article in journal (Refereed)
    Abstract [en]

    Background. Cigarette smoking during pregnancy is causally related to birthweight, but we do not know whether fetal growth restriction is a continuous process or, if not, at what stage of pregnancy it affects weight gain. Material and methods. A random sample of para 1 and 2 mothers, drawn from the population of pregnant women in Bergen and Trondheim, Norway, and Uppsala, Sweden, were examined by a detailed questionnaire concerning smoking habits, menstrual history and pregnancy dating, and subjected to morphometric sonography of their fetuses in or around week 17. Of the 547 study participants, 31.9% were smokers. Gestational age was primarily determined by the last menstrual period [LMP], except in those with irregular cycles, and in 30 cases (6.6% of those with regular cycles) in whom the biparietal diameter [BPD]-determined age deviated >14 days from the LMP-based date. Results. The analysis did not reveal any statistically significant differences between the fetuses of non-smokers, light smokers (0-9 cigarettes per day) and heavy (10+ cigarettes per day) smokers, regarding BPD, mean abdominal diameter [MAD] femur length [FL], and a 'body contour index': [BPD+FL]MAD. Conclusion. Tobacco-induced fetal growth restriction probably begins after gestational week 17.

  • 20.
    Billström, Emma
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Poromaa, Inger Sundström
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Stålberg, Karin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Asplund, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology, Molecular and Morphological Pathology.
    Hellberg, Dan
    Socioeconomic characteristics, housing conditions and criminal behavior in women with cervical intraepithelial neoplasia (CIN) between 1960 and 20062012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, p. 68-69Article in journal (Other academic)
  • 21.
    Billström, Emma
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Sundström Poromaa, Inger
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Stålberg, Karin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Asplund, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology, Molecular and Morphological Pathology.
    Hellberg, Dan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Socioeconomic characteristics, housing conditions and criminal offences among women with cervical neoplasia2013In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 92, no 8, p. 888-894Article in journal (Refereed)
    Abstract [en]

    Objective. To investigate the association between cervical neoplasia and socioeconomic factors, housing conditions and criminal offences. Design. Longitudinal observational study. Setting. Falun county hospital, Sweden. Population. A total of 1331 women diagnosed with cervical intraepithelial neoplasia I-III or cervical cancer between 1967 and 1978 were compared with 2604 age-matched controls from the same geographical area in Sweden. Methods. The Population and Housing Censuses were used for information about civil status, education, housing conditions, employment and socioeconomic status. The Swedish Register of Conviction Decisions was used to access information on criminal offences. Main outcome measures. Socioeconomic status, housing conditions, criminal offences. Results. Women with cervical neoplasia had a lower socioeconomic status and a lower educational level than their age-matched controls. They were more often divorced and did not own their home as often as controls. A significant association with criminal offences was observed, and it persisted after adjustment for socioeconomic status. Differences in socioeconomic factors between women with cervical neoplasia and their controls had not diminished in the younger, compared with the older, part of the study population. Conclusions. The results indicate that women with cervical neoplasia belong to a socioeconomically disadvantaged group. Furthermore, the study provides information about an association with criminal offences.

  • 22.
    Bjersand, Kathrine
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Poromaa, Inger Sundström
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Nygren, Peter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Oncology.
    Mahteme, Haile
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Pseudomyxoma Peritone: symptoms, treatment, prognosis and sensitivity to cytostatic drugs in vitro2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, no S159, p. 71-71Article in journal (Other academic)
  • 23.
    Björkman, Katarina
    et al.
    Falun Cent Hosp, Dept Obstet & Gynecol, Falun, Sweden..
    Wesström, Jan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology. Falun Cent Hosp, Dept Obstet & Gynecol, Falun, Sweden..
    Risk for girls can be adversely affected post-term due to underestimation of gestational age by ultrasound in the second trimester2015In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 94, no 12, p. 1373-1379Article in journal (Refereed)
    Abstract [en]

    Introduction. Post-term pregnancies are associated with greater risks for mother and child. Accurate determination of gestational age is necessary for safe care. Female fetuses have been shown to be smaller than males at the time of second-trimester ultrasound (US) examination, leading to underestimation of their age and, potentially, greater impacts of perinatal complications in post-term girls than in post-term boys. The purpose of this study was to investigate the sex ratio of post-term births and differences in perinatal complications (stillbirth, low Apgar score, low birthweight, meconium aspiration and low umbilical artery pH) between post-term boys and girls according to dating method [second-trimester US and last menstrual period (LMP)]. Material and methods. Data from gestational week >= 39 to delivery of 13 338 singleton pregnancies between 13 February 2006 and 15 January 2014, were collected from the Obstetrix (R) (Siemens Healthcare) medical records system in Dalarna County, Sweden. Results. The neonatal male: female ratio increased with gestational age after week 40, as dated by US, reaching 1.69 in gestational week 42. This ratio remained 1 throughout gestation according to dating by the LMP. Post-term pregnancy increased the risks of meconium aspiration and low Apgar score, with no sex difference observed. Conclusions. US gestational dating indicated that more boys than girls were born post-term, whereas dating according to LMP revealed no sex difference. These results support the hypothesis that female fetuses are smaller than males, leading to underestimation of their gestational age, at the time of second-trimester US examination.

  • 24. Bodker, Birgit
    et al.
    Bremme, Katarina
    Ellingsen, Liv
    Geirsson, Reynir
    Gissler, Mika
    Grunewald, Charlotta
    Hvidman, Lone
    Mulic-Lutvika, Ajlana
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Nyflot, Lill Trine
    Sorensen, Jette Led
    Ulander, Veli-Matti
    Vangen, Siri
    Maternal mortality in the Nordic countries The establishment of a Nordic maternal mortality collaboration2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, p. 46-47Article in journal (Other academic)
  • 25. Bostrom, Per
    et al.
    Lovkvist, Lena
    Edlund, Mans
    Olovsson, Matts
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Burden of illness in women with endometriosis2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, p. 37-37Article in journal (Other academic)
  • 26.
    Brodin, Thomas
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Berglund, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Hadziosmanovic, Nermin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Bergh, Torbjorn
    Olovsson, Matts
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Holte, Jan
    Antimullerian hormone predicts pregnancy and live-birth rates after assisted reproduction and reflect oocyte quality besides oocyte quantity2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, p. 35-35Article in journal (Other academic)
  • 27.
    Brodin, Thomas
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology. Carl von Linne Clin, S-75183 Uppsala, Sweden..
    Hadziosmanovic, Nermin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Berglund, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Olovsson, Matts
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology. Uppsala Univ, Dept Womens & Childrens Hlth, Uppsala, Sweden..
    Holte, Jan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology. Uppsala Univ, Dept Womens & Childrens Hlth, Uppsala, Sweden.;Carl von Linne Clin, S-75183 Uppsala, Sweden.;Ctr Reprod Biol Uppsala CRU, Uppsala, Sweden..
    Comparing four ovarian reserve markers: associations with ovarian response and live births after assisted reproduction2015In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 94, no 10, p. 1056-1063Article in journal (Refereed)
    Abstract [en]

    Introduction. We compared the ability of four different ovarian reserve tests (ORTs) to predict live births per started in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) cycle, and poor and excessive response to controlled ovarian hyperstimulation. Material and methods. This was a cohort study in a private infertility center in collaboration with Uppsala University, comprising 1230 IVF-ICSI cycles in 892 consecutive women between April 2008 and June 2011. Anti-Mullerian hormone (AMH) levels, antral follicle counts (AFC), combinations of basal levels of follicle-stimulating hormone and luteinizing hormone, and menstrual cycle lengths were analyzed for correlation and treatment outcome prediction in age-adjusted statistical models. Stepwise multivariable generalized estimating equation analyses were carried out in a sub-group with complete data on all four ORTs (620 cycles in 443 women). Odds ratios and c-statistics were calculated in the largest available set of data for each significant variable. Primary outcomes were live birth rate per started cycle and poor and excessive ovarian response to controlled ovarian hyperstimulation (defined by the ovarian sensitivity index). Results. All ORTs correlated significantly with each other, with the strongest correlation between AFC and AMH (r = 0.71, p < 0.0001). Univariately, AMH and age equivalently predicted live birth (c-statistic 0.61), and together they provided a significantly better model (c-statistic 0.64). For prediction of poor and excessive response the best model included AMH, AFC and age (c-statistic 0.89). Conclusions. AMH improves the ability to estimate live birth rates after assisted reproduction compared with female age alone. AMH, AFC and age together constituted the best model for prediction of ovarian response.

  • 28. Campo, S
    et al.
    Campo, V
    Gambadauro, Pietro
    Short-term and long-term results of resectoscopic myomectomy with and without pretreatment with GnRH analogs in premenopausal women2005In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 84, no 8, p. 756-60Article in journal (Refereed)
  • 29.
    Cesta, Carolyn E.
    et al.
    Karolinska Inst, Dept Med Epidemiol & Biostat, Nobels Vag 12a, S-17177 Stockholm, Sweden..
    Johansson, Anna L. V.
    Karolinska Inst, Dept Med Epidemiol & Biostat, Nobels Vag 12a, S-17177 Stockholm, Sweden..
    Hreinsson, Julius
    Karolinska Univ Hosp, Dept Obstet & Gynecol, Reprod Med, Stockholm, Sweden..
    Rodriguez-Wallberg, Kenny A.
    Karolinska Univ Hosp, Dept Obstet & Gynecol, Reprod Med, Stockholm, Sweden.;Karolinska Inst, Dept Oncol Pathol, Stockholm, Sweden..
    Olofsson, Jan I.
    Karolinska Univ Hosp, Dept Obstet & Gynecol, Reprod Med, Stockholm, Sweden.;Karolinska Inst, Dept Womens & Childrens Hlth, Stockholm, Sweden..
    Holte, Jan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. Carl von Linne Clin, Uppsala, Sweden ; Univ Agr Sci Uppsala, Ctr Reprod Biol Uppsala, Uppsala, Sweden; Uppsala Univ, Uppsala, Sweden..
    Wramsby, Håkan
    St Gorans Sjukhus, IVF Kliniken Stockholm, Stockholm, Sweden..
    Wramsby, Margareta
    Fertilitetsctr Stockholm, Stockholm, Sweden..
    Cnattingius, Sven
    Karolinska Inst, Dept Med Solna, Clin Epidemiol Unit, Stockholm, Sweden..
    Skalkidou, Alkistis
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Iliadou, Anastasia Nyman
    Karolinska Inst, Dept Med Epidemiol & Biostat, Nobels Vag 12a, S-17177 Stockholm, Sweden..
    A prospective investigation of perceived stress, infertility-related stress, and cortisol levels in women undergoing in vitro fertilization: influence on embryo quality and clinical pregnancy rate2018In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 97, no 3, p. 258-268Article in journal (Refereed)
    Abstract [en]

    Introduction

    Women undergoing fertility treatment experience high levels of stress. However, it remains uncertain if and how stress influences in vitro fertilization (IVF) cycle outcome. This study aimed to investigate whether self-reported perceived and infertility-related stress and cortisol levels were associated with IVF cycle outcomes.

    Material and methods

    A prospective cohort of 485 women receiving fertility treatment was recruited from September 2011 to December 2013 and followed until December 2014. Data were collected by online questionnaire prior to IVF start and from clinical charts. Salivary cortisol levels were measured. Associations between stress and cycle outcomes (clinical pregnancy and indicators of oocyte and embryo quality) were measured by logistic or linear regression, adjusted for age, body mass index, education, smoking, alcohol and caffeine consumption, shiftwork and night work.

    Results

    Ultrasound verified pregnancy rate was 26.6% overall per cycle started and 32.9% per embryo transfer. Stress measures were not associated with clinical pregnancy: when compared with the lowest categories, the adjusted odds ratio (OR) and 95% confidence interval (CI) for the highest categories of the perceived stress score was 1.04 (95% CI 0.58-1.87), infertility-related stress score was OR = 1.18 (95% CI 0.56-2.47), morning and evening cortisol was OR = 1.18 (95% CI 0.60-2.29) and OR = 0.66 (95% CI 0.34-1.30), respectively.

    Conclusions

    Perceived stress, infertility-related stress, and cortisol levels were not associated with IVF cycle outcomes. These findings are potentially reassuring to women undergoing fertility treatment with concerns about the influence of stress on their treatment outcome.

  • 30. Cleverly, K
    et al.
    Gambadauro, Pietro
    Navaratnarajah, R
    Paraneoplastic anti-N-methyl-D-aspartate receptor encephalitis: have you checked the ovaries?2014In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 93, no 7, p. 712-5Article in journal (Refereed)
  • 31.
    Danielsson, Ingela
    et al.
    Dept of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden.
    Blom, Helena
    Department of Obstetrics and Gynecology, Sundsvall Hospital, Sweden.
    Nilses, Carin
    Department of Clinical Sciences, Obstetrics and Gynecology, Umea University, Sweden.
    Heimer, Gun
    Uppsala University, National Centre for Knowledge on Men.
    Högberg, Ulf
    Department of Clinical Sciences, Obstetrics and Gynecology, Umea University, Sweden.
    Gendered patterns of high violence exposure among Swedish youth2009In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 88, no 5, p. 528-535Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The WHO describes violence as a global public health problem. In contrast to domestic violence, violence against youth has been little explored. Our aims were to investigate the prevalence and gender differences in relation to emotional, physical and sexual abuse among young men and women attending youth health centers in Sweden, the current adverse effects of the abuse and the perpetrators of the abuse. DESIGN: Cross-sectional study. SETTING: Nationally representative youth health centers in Sweden. POPULATION AND METHODS: In total, 2,250 women and 920 men aged 15-23 years answered a validated questionnaire about emotional, physical and sexual abuse. RESULTS: A total of 33% (CI: 31-35) of the young women and 18% (CI: 16-21) of the young men had been exposed to emotional abuse during the past year. For physical abuse, 18% (CI: 17-20) of the women and 27% (CI: 24-30) of the men stated that they had been abused during the past year. The gender differences for sexual abuse were pronounced, with 14% (CI: 12-15) of the young women and 4.7% (CI: 3.3-6.0) of the men stating that they had been abused during the past 12 months. The young women reported more severe adverse effects from all types of abuse and were more often abused by a person close to them. CONCLUSIONS: The exposure to violence among young people is alarming and presents prominent gender differences, and should be taken into serious consideration as it is a matter of health, democracy and human rights.

  • 32.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Oral progesterone opposing postmenopausal estrogen replacement therapy1995In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 74, no 5, p. 404-405Article in journal (Refereed)
  • 33.
    Darj, Elisabeth
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Lyrenäs, Sven
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Insulin-like growth factor binding protein-1, a quick way to detect amniotic fluid1998In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 77, no 3, p. 295-297Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    The detection of premature rupture of membranes (PROM) is essential to the management of pregnancy. Various tests, all with different limitations, have been used to diagnose PROM. Insulin-like growth factor binding protein-1 (IGFBP-1) is present in an essentially higher concentration in amniotic fluid, than in serum, cervical mucous, urine and seminal plasma. A commercial kit, with monoclonal antibodies to IGFBP-1 attached to a stick, is available. The aim of this study was to investigate whether a rapid dipstick test could confirm or exclude the presence of amniotic fluid.

    METHODS:

    A multicenter study, involving six departments of obstetrics and gynecology in Sweden, was designed to evaluate the new dipstick technique of diagnosing the presence of amniotic fluid in the vagina. One hundred and seventy-four women were examined. Forty-six women with obvious PROM, 29 women without PROM and 99 women with suspected PROM.

    RESULTS:

    Forty-four out of forty-six women with obvious PROM had a positive PROM-TEST. Twenty-seven out of twenty-nine women without PROM had a negative PROM-TEST, giving a sensitivity of 95.7% and a specificity of 93.1%. Among the women with suspected rupture of membranes, the sensitivity was 70.8%, the specificity 88.2% and the positive predictive value (PPV) 92%.

    CONCLUSION:

    IGFBP is present in high concentration in amniotic fluid. The dipstick test with monoclonal antibodies to IGFBP-1 is rapid and has a high PPV, sensitivity and specificity. It is a useful complement to the existing arsenal of tests to detect PROM.

  • 34.
    Drevin, Jennifer
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Stern, Jenny
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Annerbäck, Eva-Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD).
    Peterson, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Berglund, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Uppsala University, National Centre for Knowledge on Men.
    Larsson, Margareta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Kristiansson, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Adverse childhood experiences influence development of pain during pregnancy.2015In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 94, no 8, p. 840-846Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate the association between adverse childhood experiences (ACE) and pain with onset during pregnancy.

    DESIGN: Cross-sectional study.

    SETTING: Eighteen antenatal clinics in southern Mid-Sweden.

    SAMPLE: Of 293 women invited to participate, 232 (79%) women agreed to participate in early pregnancy and were assessed in late pregnancy.

    METHODS: Questionnaires were distributed in early and late pregnancy. The questionnaires sought information on socio-demography, ACE, pain location by pain drawing and pain intensity by visual analogue scales. Distribution of pain was coded in 41 predetermined areas.

    MAIN OUTCOME MEASURES: Pain in third trimester with onset during present pregnancy: intensity, location and number of pain locations.

    RESULTS: In late pregnancy, 62% of the women reported any ACE and 72% reported any pain location with onset during the present pregnancy. Among women reporting any ACE the median pain intensity was higher compared with women without such an experience (p = 0.01). The accumulated ACE displayed a positive association with the number of reported pain locations in late pregnancy (rs  = 0.19, p = 0.02). This association remained significant after adjusting for background factors in multiple regression analysis (p = 0.01). When ACE was dichotomized the prevalence of pain did not differ between women with and without ACE. The subgroup of women reporting physical abuse as a child reported a higher prevalence of sacral and pelvic pain (p = 0.0003 and p = 0.02, respectively).

    CONCLUSIONS: Adverse childhood experiences were associated with higher pain intensities and larger pain distributions in late pregnancy, which are risk factors for transition to chronic pain postpartum.

  • 35.
    Eckerdal, Patricia
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Georgakis, Marios K.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece .
    Kollia, Natasa
    Department of Biostatistics, Harokopio University, Athens, Greece.
    Wikström, Anna-Karin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Obstetrics.
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Skalkidou, Alkistis
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Delineating the association between mode of delivery and postpartum depression symptoms: A  longitudinal study2018In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 97, no 3, p. 301-311, article id 29215162Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Although a number of perinatal factors have been implicated in the etiology of postpartum depression, the role of mode of delivery remains controversial. Our aim was to explore the association between mode of delivery and postpartum depression, considering the potentially mediating or confounding role of several covariates. MATERIAL AND METHODS: In a longitudinal-cohort study in Uppsala, Sweden, with 3888 unique pregnancies followed up postpartum, the effect of mode of delivery (spontaneous vaginal delivery, vacuum extraction, elective cesarean section, emergency cesarean section) on self-reported postpartum depression symptoms (Edinburgh Postnatal Depression Scale >/=12) at 6 weeks postpartum was investigated through logistic regression models and path analysis. RESULTS: The overall prevalence of postpartum depression was 13%. Compared with spontaneous vaginal delivery, women who delivered by emergency cesarean section were at higher risk for postpartum depression 6 weeks after delivery in crude (odds ratio 1.45, 95% confidence interval 1.04-2.01) but not in adjusted analysis. However, the path analysis revealed that emergency cesarean section and vacuum extraction were indirectly associated with increased risk of postpartum depression, by leading to postpartum complications, self-reported physical symptoms postpartum, and therefore a negative delivery experience. In contrast, history of depression and fear of delivery increased the odds of postpartum depression and led more frequently to elective cesarean section; however, it was associated with a positive delivery experience. CONCLUSIONS: Mode of delivery has no direct impact on risk of postpartum depression; nevertheless, several modifiable or non-modifiable mediators are present in this association. Women delivering in an emergency setting by emergency cesarean section or vacuum extraction, and reporting negatively experienced delivery, constitute a high-risk group for postpartum depression.

  • 36. Ekeus, Cecilia
    et al.
    Cnattingius, Sven
    Hjern, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Epidural analgesia during labor among immigrant women in Sweden2010In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 89, no 2, p. 243-249Article in journal (Refereed)
    Abstract [en]

    Objective. To investigate differences in the use of epidural analgesia (EDA) during labor between native Swedish and immigrant women and whether such possible differences could be explained by other maternal factors or birthweight. Design. Population-based register study. Setting. Nationwide study in Sweden. Population. A total of 455,274 primiparous women, who gave birth to a singleton infant at 37-41 completed gestational weeks during 1992-2005. Of the 72,086 (16%) immigrants, data on 31,148 women from the eight most common countries of origin were analyzed to test our hypotheses. Methods. Register study with perinatal data from the Medical Birth Register and socio-demographic variables from national income and population registers. Main outcome measure. Use of EDA during vaginal delivery. Results. Compared with native Swedish women, EDA was more often used by women from Chile, odds ratio (OR) 1.39 (95% confidence interval (CI) 1.23-1.57); Iran, OR 1.38 (1.26-1.53); Poland, OR 1.22 (1.08-1.37) and Finland, OR 1.10 (1.03-1.17) after adjustments for perinatal and socio-demographic confounders, while EDA was less often used among women from Somalia, OR 0.57 (0.46-0.70); Iraq, OR 0.71 (0.64-0.78); Turkey, OR 0.77(0.69-0.86) and Yugoslavia, OR 0.85 (0.79-0.91). Having a native Swedish partner increased the use of EDA in immigrant women. Conclusion. EDA use during labor varies more by maternal country of origin than by socio-economic factors. This suggests that expectations of care from the country of origin continue to influence the use of EDA after immigration to Sweden.

  • 37. Ekman-Ordeberg, Gunvor
    et al.
    Hellgren, Margareta
    Akerud, Anna
    Andersson, Eva
    Dubicke, Aurelija
    Sennström, Maria
    Byström, Birgitta
    Tzortzatos, Gerasimos
    Gomez, Maria F
    Edlund, Måns
    Lindahl, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Biochemistry and Microbiology.
    Malmström, Anders
    Low molecular weight heparin stimulates myometrial contractility and cervical remodeling in vitro2009In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 88, no 9, p. 984-989Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The low molecular weight heparin, Dalteparin, shortens human labor time. The aim of this study was to investigate if the mechanism behind this effect involves myometrial contractility and cervical ripening and if the anticoagulative activity is necessary for its effect. DESIGN: Experimental in vitro study. SETTING: Lund University and Karolinska Institute, Sweden. METHODS: The effect of low molecular weight heparins with or without anticoagulative properties on myometrial contractility was measured in vitro on smooth muscle strips from biopsies obtained at elective cesarean sections. The effects on cervical ripening were assessed in cervical fibroblasts cultured from explants of cervical biopsies obtained at delivery. MAIN OUTCOME MEASURES: Mean force and number of contractions in uterine smooth muscle strips and interleukin-8 (IL-8) secretion in cervical fibroblasts. RESULTS: Myometrial smooth muscle strips pretreated with low molecular weight heparins showed increased contractile activity compared to untreated smooth muscle strips. Secretion of IL-8 from cultured cervical fibroblasts was significantly increased after treatment with low molecular weight heparin. Both these effects were independent of anticoagulative activity of the low molecular weight heparin. CONCLUSIONS: A possible underlying mechanism for the shortened labor time after low molecular weight heparin treatment is enhanced myometrial contractility and an increased IL-8 secretion in cervical fibroblast, mimicking the final cervical ripening in vivo. Our data support the notion that anticoagulant activity is not required to promote labor.

  • 38.
    Ekstrand, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Larsson, Margareta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Advance provision of emergency contraceptive pills reduces treatment delay: a randomized controlled trial among Swedish teenage girls2008In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 87, no 3, p. 354-359Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To evaluate an intervention involving advance provision of emergency contraceptive pills (ECP) to Swedish teenage girls. MATERIAL AND METHODS: Some 420 girls aged 15-19, requesting ECP at a local youth clinic were randomly assigned to intervention group (IG) (n=214) or control group (CG) (n=206). Both groups received ECP on request. The IG received one extra dose of ECP, condoms and an information leaflet regarding ECP and condom use. Main outcome measures were differences between IG and CG regarding ECP use, time span between unprotected intercourse and ECP intake, contraceptive use, and sexual risk taking. Questionnaires were completed at the initial visit, and the girls were followed up by structured telephone interviews 3 and 6 months later. RESULTS: At the 3-month follow-up, girls in the IG were almost twice as likely to have used ECP compared to girls in the CG (IG: 24.0%, CG: 13%, p=0.02), and they used it sooner after unprotected intercourse (mean time IG: 13.61 h, CG: 25.47 h, p=0.007). Significant differences persisted 6 months after the intervention (ECP use IG: 31%, CG: 19%, p=0.01; and mean time IG: 15.59 h, CG: 26.38 h, p=0.006). No significant differences were found in the use of regular hormonal contraceptives or condoms at either follow-up. About 40% of the girls in both groups had risked pregnancy during the follow-up period, but only half of these had used ECP. CONCLUSIONS: This intervention shortened the time interval from unprotected intercourse to pill intake without jeopardising contraceptive use and without increasing sexual risk taking.

  • 39.
    Ekstrand, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Larsson, Margareta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    von Essen, Louise
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Swedish teenager perceptions of teenage pregnancy, abortion, sexual behavior, and contraceptive habits: a focus group study among 17-year-old female high-school students2005In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 84, no 10, p. 980-986Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Sweden has the highest abortion numbers among the Nordic countries. Since 1995, the abortion rate among teenagers has increased by nearly 50%. We therefore undertook a study where the overall aim was to gain a deeper understanding on which factors female teenagers believe may explain the increasing numbers of teenage abortions. Teenagers' perceptions of teenage pregnancy, abortion, sexual behavior, and contraceptive habits were investigated. METHODS: Six focus group interviews with 17-year-old Swedish girls were conducted. The interviews were tape-recorded, transcribed verbatim, and analyzed by manifest content analysis. RESULTS: Negative attitudes toward teenage pregnancy and supportive attitudes toward abortion were expressed. Risk-taking behaviors such as negligence in contraceptive use and intercourse under the influence of alcohol were suggested as main reasons behind the increasing numbers of abortions among Swedish teenagers. The contemporary, sexualized, media picture was believed to influence adolescents' sexual behavior, and liberal attitudes toward casual sex were expressed. Girls were perceived as more obliged than boys in taking responsibility for contraceptive compliance and avoidance of pregnancy. The apprehension that hormonal contraceptives cause negative side-effects was widely spread, and the participants were found to have a somewhat limited knowledge of abortion. The majority were unsatisfied with the quality of sexual education provided by the schools. CONCLUSION: Possible reasons for increased abortion numbers among teenagers in Sweden could be liberal attitudes toward casual sex in combination with negligence in contraceptive use, use of alcohol followed by sexual risk-taking, fear of hormonal contraceptives, and a deterioration of sexual education in the schools.

  • 40. Ekéus, Cecilia
    et al.
    Lindblad, Frank
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience.
    Hjern, Anders
    Short stature, smoking habits and birth outcome in international adoptees in Sweden2008In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 87, no 12, p. 1309-14Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate short stature and smoking habits as risk factors for birth outcome in international adoptees in comparison with non-adopted mothers. DESIGN: Prospective cohort study. SETTING: Nationwide study in Sweden. POPULATION: Two study groups were identified from mothers who were born 1968-1979 and gave birth during 1982-2001-3,610 mother-child dyads with a mother adopted from a non-European country and 336,992 mother-child dyads with a mother born in Sweden. METHOD: Register study. OUTCOME MEASURES: Pre-eclampsia, instrumental delivery, preterm delivery, small for gestational age (SGA), Apgar score, cephalhematoma and perinatal mortality and birth weight. RESULTS: Short stature and smoking were more common in international adoptees compared with non-adopted, odds ratios (ORs) 29.07 (95% C.I.: 25.29-33.42) and 1.39 (1.27-1.52), respectively. International adoptees had a slightly increased risk for instrumental delivery (OR: 1.42; 1.32-1.54) and preterm delivery (<37 weeks) (OR: 1.39; 1.24-1.56) and there was a slightly increased risk for SGA (OR: 1.24; 1.01-1.52) in their offspring. However, when we adjusted for maternal height, preterm delivery was the only outcome that remained statistically significant. Adjustment for smoking habits had marginal effects on all outcomes. CONCLUSION: The short stature of international adoptees increased their risk for delivery and birth complications in a predictable manner, but otherwise outcomes were very similar to the general population. No special obstetric monitoring is indicated by adoption status in itself.

  • 41. Elvander, Charlotte
    et al.
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Ekeus, Cecilia
    The influence of fetal head circumference on labor outcome: a population-based register study2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, no 4, p. 470-475Article in journal (Refereed)
    Abstract [en]

    Objective. To investigate the association between postnatal head circumference and the occurrence of the three main indications for instrumental delivery, namely prolonged labor, signs of fetal distress and maternal distress. We also studied the association between postnatal fetal head circumference and the use of vacuum extraction and emergency cesarean section.

    Design. Population-based register study.

    Setting. Nationwide study in Sweden. Population. A total of 265 456 singleton neonates born to nulliparous women at term between 1999 and 2008 in Sweden.

    Methods. Register study with data from the Swedish Medical Birth Register. Main outcome measures. Prolonged labor, signs of fetal distress, maternal distress, use of vacuum extraction and emergency cesarean section.

    Results. The prevalence of each outcome increased gradually as the head circumference increased. Compared with women giving birth to a neonate with average size head circumference (35 cm), women giving birth to an infant with a very large head circumference (3941 cm) had significantly higher odds of being diagnosed with prolonged labor [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.331.67], signs of fetal distress (OR 1.73, 95% CI 1.492.03) and maternal distress (OR 2.40, 95% CI 1.962.95). The odds ratios for vacuum extraction and cesarean section were thereby elevated to 3.47 (95% CI 3.103.88) and 1.22 (95% CI 1.041.42), respectively. The attributable risk proportion percentages associated with vacuum extraction and cesarean section were 46 and 39%, respectively among the cases exposed to a head circumference of 3741 cm.

    Conclusions. Large fetal head circumference is associated with complicated labor and is etiological to a considerable proportion of assisted vaginal births and emergency cesarean sections.

  • 42.
    Eriksson, Lena
    et al.
    Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm.
    Haglund, Bengt
    Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Odlind, Viveca
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Kieler, Helle
    Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm.
    Health consequences of prophylactic exposure to antenatal corticosteroids among children born late preterm or term2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, no 12, p. 1415-21Article in journal (Refereed)
    Abstract [en]

    Objective. To investigate the duration of effects and health consequences of earlier antenatal corticosteroid exposure in infants born late preterm or term. Design. Observational cohort study. Setting. Children born after gestational week 34 in Sweden, 1976-1997, whose mothers were hospitalized for imminent preterm delivery. The children were followed to their 11th birthday. Sample. The cohort consisted of 11 873 infants, of whom 8620 were exposed. Methods. Exposure was estimated at hospital level. Infants born at a hospital practicing antenatal corticosteroid administration were classified as exposed. Estimation of hospital routines was based on questionnaire data, telephone interviews with physicians and pharmacy sales, validated in a random sample of medical records. Logistic regression was used to assess associations with adjustments for pregnancy length, birth year and hospital level. Main outcome measures. Rates and odds ratios of mortality, respiratory distress syndrome, bronchopulmonary dysplasia, epilepsy, cerebral palsy, childhood diabetes, birthweight, length and head circumference for all infants, and for preterm and term infants, respectively. Results. Exposed infants had reduced risks of respiratory distress syndrome (odds ratio 0.54, 95% confidence interval 0.35-0.83) and small head circumference (odds ratio 0.47, 95% confidence interval 0.36-0.61), and an increased risk of low Apgar scores (odds ratio 1.40, 95% confidence interval 1.01-1.94), most pronounced in infants born after gestational week 37. Conclusions. Infants born after gestational week 34 seem to benefit from earlier antenatal corticosteroid administration, with reduced risks of respiratory distress syndrome. However, the treatment was less beneficial for term infants, because they also had increased risk of low Apgar scores.

  • 43. Eriksson, Lena
    et al.
    Haglund, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Odlind, Viveca
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Kieler, Helle
    Short and long-term effects of antenatal corticosteroids assessed in a cohort of 7,827 children born preterm2009In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 88, no 8, p. 933-938Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To study the benefits of antenatal corticosteroids (ACS) in clinical settings and to evaluate the occurrence of long-term neuro-sensory effects such as epilepsy and cerebral palsy (CP). DESIGN: Observational population-based study including all births between gestational weeks 24 and 34 during 1976-1997 in Sweden. Exposure to ACS was evaluated at hospital level. Children were followed up to their ninth birthday. SAMPLE AND METHODS: Seven thousand eight hundred twenty-seven infants of which 5,632 were exposed to ACS. Data on hospital ACS routines was based on questionnaires and interviews with physicians and pharmacy sales. Outcomes were obtained from the national health registers and assessed according to gender of the child. Logistic regression was used to assess associations. MAIN OUTCOME MEASURES: Neonatal death, low Apgar score, respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), CP, and epilepsy. RESULTS: After adjustment, exposed infants had reduced risks of RDS (OR 0.80, 95% CI 0.70-0.92), late neonatal death (OR 0.86, 95% CI 0.57-1.29), BPD (OR 0.87, 95% CI 0.62-1.22), ROP (OR 0.80, 95% CI 0.48-1.32), IVH (OR 0.93, 95% CI 0.67-1.3), and CP (OR 0.82, 95% CI 0.58-1.15). Males had a higher risk of epilepsy (OR 1.74, 95% CI 0.85-3.55) than females (OR 0.50, 95% CI 0.25-1.03). CONCLUSION: The results confirm the beneficial effect of ACS regarding RDS in clinical settings. Except for a tendency to increased risk of epilepsy among male infants there were no increased risks of neuro-sensory outcomes.

  • 44.
    Esscher, Annika
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Haglund, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Essen, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Maternal mortality in Sweden 1988-2007. How many deaths were there, actually?2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, p. 78-79Article in journal (Other academic)
  • 45.
    Esscher, Annika
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Haglund, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Maternal mortality in Sweden 1988-2007: more deaths than officially reported2013In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 92, no 1, p. 40-46Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE:

    To obtain more accurate calculations of maternal and pregnancy-related mortality ratios in Sweden from 1988 to 2007 by using information from national registers and death certificates.

    DESIGN:

    A national register-based study, supplemented by a review of death certificates.

    SETTING:

    Sweden, 1988 to 2007.

    POPULATION:

    The deaths of 27 957 women of reproductive age (15 to 49 years).

    METHODS:

    The Swedish Cause of Death Register, Medical Birth Register, and National Patient Register were linked. All women with a diagnosis related to pregnancy in at least one of these registers within one year prior to death were identified. Death certificates were reviewed to ascertain maternal deaths. Maternal mortality ratio, the number of maternal deaths/100 000 live births (excluding and including suicides); and pregnancy-related mortality ratio (number of deaths within 42 days after termination of pregnancy, irrespective of cause of death/100 000 live births) were calculated.

    MAIN OUTCOME MEASURES:

    Direct and indirect maternal deaths and pregnancy-related deaths.

    RESULTS:

    The maternal mortality ratio in Sweden, based on the current method of identifying maternal deaths, was 3.6. After linking registers and reviewing death certificates, we identified 64% more maternal deaths, resulting in a ratio of 6.0 (or 6.5 if suicides are included). The pregnancy-related mortality ratio was 7.3. A total of 478 women died within a year after being recorded with a diagnosis related to pregnancy.

    CONCLUSIONS:

    By including the 123 cases of maternal death identified in this study, the mean maternal mortality ratio from 1988-2007 was 64% higher than reported to the World Health Organization.

  • 46.
    Essen, Birgitta
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Binder, Pauline
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Johnsdotter, Sara
    Not too far to walk but too far for reciprocity: Maternal mortality in a migration context using the 'three delays' framework2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, no S159, p. 79-80Article in journal (Other academic)
  • 47.
    Essén, Birgitta
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Johnsdotter, Sara
    Medical Anthropology, Faculty of Health and Society, Malmö University, Sweden.
    Transnational surrogacy: reproductive rights for whom?2015In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 94, no 5, p. 449-450Article in journal (Refereed)
  • 48. Fadl, H. E.
    et al.
    Östlund, I.K.M.
    Hanson, Ulf S. B.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Outcomes of gestational diabetes in Sweden depending on country of birth2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, no 11, p. 1326-1330Article in journal (Refereed)
    Abstract [en]

    Objective. To analyze maternal and neonatal outcomes for women with gestational diabetes mellitus (GDM) in Sweden, depending on country of birth (Nordic vs. non-Nordic women). Design. Population-based cohort study using the Swedish Medical Birth register. Setting. Data on pregnant women in Sweden with diagnosed GDM. Population. All singleton births to women with GDM between 1998 and 2007 (n = 8560). Methods. Logistic regression in an adjusted model to assess the risk of adverse maternal and neonatal outcomes. Chi-squared tests or Student's unpaired t-tests were used to analyze differences between maternal and fetal characteristics. Main outcome measures. Maternal and neonatal complications. Results. GDM incidence was higher at 2.0% among non-Nordic women, compared with 0.7% in the Nordic group. The non-Nordic women were older, had less chronic hypertensive disease, smoked less, and had lower BMI and shorter height. Preeclampsia was significantly lower in the non-Nordic group. The mean birthweight (3561 vs. 3698 g, p < 0.001) and the large-for-gestational age rate (11.7 vs. 17.5%, p < 0.001) were significantly lower in the non-Nordic group. Large-for-gestational age was dependent on maternal height [crude odds ratio 0.6 (0.5-0.7) and adjusted odds ratio 0.8 (0.6-0.9)]. Conclusions. Non-Nordic women with GDM in Sweden have better obstetrical and neonatal outcomes than Nordic women. These results do not support the idea of inequality of health care. Large-for-gestational age as a diagnosis is highly dependent on maternal height, which raises the question of the need for individualized growth curves.

  • 49.
    Fadl, Helena E.
    et al.
    Univ Orebro, Sch Hlth & Med Sci, Dept Obstet & Gynecol, SE-70182 Orebro, Sweden..
    Gardefors, Susanne
    Univ Orebro, Sch Hlth & Med Sci, Dept Obstet & Gynecol, SE-70182 Orebro, Sweden..
    Hjertberg, Ragnhild
    UltraGyn Clin, Stockholm, Sweden..
    Nord, Eva
    Karolinska Univ Hosp, Dept Obstet & Gynecol, Stockholm, Sweden..
    Persson, Bengt
    Karolinska Inst, Stockholm, Sweden..
    Schwarcz, Erik
    Univ Orebro, Sch Hlth & Med Sci, Dept Internal Med, SE-70182 Orebro, Sweden..
    Aman, Jan
    Univ Orebro, Sch Hlth & Med Sci, Dept Pediat, SE-70182 Orebro, Sweden..
    Ostlund, Ingrid K.
    Hanson, Ulf S. B.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology. Univ Orebro, Sch Hlth & Med Sci, Dept Obstet & Gynecol, SE-70182 Orebro, Sweden..
    Randomized controlled study in pregnancy on treatment of marked hyperglycemia that is short of overt diabetes2015In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 94, no 11, p. 1181-1187Article in journal (Refereed)
    Abstract [en]

    IntroductionA randomized multicenter study was conducted in the Stockholm-orebro areas in Sweden to evaluate how treatment aiming at normoglycemia affects fetal growth, pregnancy and neonatal outcome in pregnant women with severe hyperglycemia. Material and methodsPregnant women with hyperglycemia defined as fasting capillary plasma glucose <7.0 mmol/L and a two-hour plasma glucose value 10.0 and <12.2 mmol/L following a 75-g oral glucose tolerance test (OGTT) diagnosed before 34 weeks of gestation were randomized to treatment (n=33) or controls (n=36). Women assigned to the control group were blinded for the OGTT results and received routine care. The therapeutic goal was fasting plasma glucose 4-5 mmol/L, and <6.5 mmol/L after a meal. Primary outcomes were size at birth and number of large-for-gestational age (>90th percentile) neonates. Secondary outcomes were pregnancy complications, neonatal morbidity and glycemic control. ResultsThe planned number of participating women was not reached. There was a significantly reduced rate of large-for-gestational age neonates, 21 vs. 47%, P<0.05. Group differences in pregnancy complications and neonatal morbidity were not detected because of limited statistical power. In total, 66.7% of the women in the intervention group received insulin. Of all measured plasma glucose values, 64.1% were in the target range, 7.2% in the hypoglycemic range and 28.7% above target values. There were no cases of severe hypoglycemia. ConclusionsAiming for normalized glycemia in a pregnancy complicated by severe hyperglycemia reduces fetal growth but is associated with an increased rate of mild hypoglycemia.

  • 50. Ferm Widlund, Kjerstin
    et al.
    Gunnarsson, Cecilia
    Nordin, Karin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Hansson, Mats G
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Centre for Research Ethics and Bioethics.
    Pregnant women are satisfied with the information they receive about prenatal diagnosis, but are their decisions well informed?2009In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 88, no 10, p. 1128-1132Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE. To survey the information about prenatal diagnosis that midwives give to pregnant women and to find out how the women experience the information. Furthermore, to evaluate the midwives' opinion about their knowledge and personal need for education. DESIGN. Descriptive cross-sectional study. SETTING. The southeast healthcare region of Sweden. METHODS. One hundred and fifty-seven midwives and 150 pregnant women were invited to reply to a confidential questionnaire in 2008. RESULTS. The reply rate was 78% for the midwives and 53% for the women. Ninety-six percentage of the midwives used < or =10 minutes to inform women about prenatal diagnosis. Seventy-two percentage always informed about the advantages and 41% about the choice to continue or terminate the pregnancy if a serious abnormality was detected. In addition, 41% considered that they had sufficient knowledge to inform about prenatal diagnosis, while 84% wanted additional education. Seventy-six percentage of the women took the decision to have prenatal diagnosis as soon as they found out that they were pregnant. A majority considered that they had been given enough time for questions and reflections. CONCLUSIONS. There was discrepancy between the amount of information, which midwives gave to pregnant women about prenatal diagnosis compared to what would be needed for a complete understanding of the relevant medical facts and the risks involved, but even so the women were satisfied with the information.

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