Cohort Of Nulliparous Women Research Articles

Assessment of Involuntary PFM Contractions in Comparison with Existing Literature and IUGA/ICS Terminology Reports

Introduction and HypothesisInvoluntary pelvic floor muscle (PFM) contractions are thought to occur during an increase in intra-abdominal pressure (IAP). Although no studies have assessed their presence in women with normal pelvic floor (PF) function, existing literature links the absence of involuntary PFM contractions to various PF dysfunctions. This study rectifies this lacuna by evaluating involuntary PFM contractions during IAP in healthy nulliparous women with no PF dysfunction, using visual observation and vaginal palpation. Results were compared with the literature and the IUGA/ICS Terminology Reports.MethodsNulliparous (n=149) women performed three sets of three maximal coughs. Visual observation and vaginal palpation were conducted in the standing and supine positions. The women were not instructed to contract their PFMs. Occurrence rates were calculated for each assessment method and position; differences between positions were analyzed using the Chi-squared test.ResultsRates of occurrence of involuntary PFM contraction were low across both assessments and positions (5–17%). Significant differences were found between standing (5%) and supine (15%) positions for visual observation, but not vaginal palpation (15%, 17% respectively). Occurrence rates also differed compared with the literature and terminology reports.ConclusionsContrary to clinical expectations, rates of occurrence of involuntary PFM contraction among our cohort of nulliparous women were extremely low. Digital palpation results showed high agreement with the terminology reports, but only partial agreement was observed for the visual observation results. Our study underscores the need for more research aimed at defining normal involuntary PF functions, a review of our understanding of involuntary PFM contractions, and better standardized guidelines for involuntary PFM assessment methods.

Reference Data on the Normal Abdominal Wall Anatomy and Baseline Characteristics in Seventy-One Nulliparous Women.

Aims: The aim of this study was to describe the prepartum anatomy of the abdominal wall in a cohort of nulliparous women, for use as a reference for management of patients with postpartum abdominal wall insufficiency with or without rectus diastasis. Materials and Methods: Seventy-one women were examined with ultrasonography of the abdominal wall. The inter-recti distance (IRD), anatomical variations of the linea semilunaris, and the oblique muscles were assessed. The waistline was measured during activation and relaxation of the abdominal core. Participant characteristics were registered. Questionnaires regarding habitual physical activity (Baecke), low back pain (Oswestry), physical functioning (DRI), urinary incontinence (UDI-6 and IIQ-7), and quality-of-life (SF-36) were answered. Results: Mean age was 30.5years (range 19-50years) and mean BMI 23.5kg/m2 (range 18-37). Ultrasonography showed a mean IRD of 10mm (range 3-24) at the superior border of the umbilicus, 9mm (4-20) 3cm above the umbilicus, and 2mm (-5-10) 2cm below the umbilicus. The mean thickness of the linea alba was 3mm (1.5-5) and mean distances between the lateral edge of the rectus muscle and the external, internal, and transverse oblique muscles were 12mm (-10-28), 1mm (-14-13) and 15mm (-14-32) at umbilicus level. Responses to the DRI, UDI-6, IIQ-7 and Oswestry questionnaires showed generally lower scores than the normal population whereas Baecke and SF-36 scores were similar. Conclusion: This study provides baseline data on normal abdominal wall anatomy in a healthy nulliparous female cohort, as well as levels of activity, physical function, disability, and quality-of-life.

OC-063 BASELINE DATA AND NORMAL ANATOMY OF THE ABDOMINAL WALL IN AN OBSERVATIONAL PROSPECTIVE COHORT STUDY OF NULLIPAROUS WOMEN

Abstract Aims The aim of this study was to describe the pre-partum anatomy of the abdominal wall in a cohort of nulliparous women, with the main purpose to use as a reference for management of patients with postpartum abdominal core instability. Materials & Methods Seventy consecutive women were examined with ultrasonography measuring inter-recti distance (IRD), anatomical variations of linea semilunaris and the oblique muscles. Waistline was assessed during activated and relaxed abdominal core. Participant characteristics were registered. Questionnaires regarding habitual physical activity (Baecke), low back pain (Oswestry), physical functioning (DRI), urinary incontinence (UDI-6 and IIQ-7) and quality of life (SF-36) were answered. Results Response rate was 100%. Mean age was 30.5 years (19–50), mean BMI 23.5 kg/m2 (18.4–37.1). Ultrasonography showed a mean IRD 1.02 mm (0.27–2.35) at the superior border of the umbilicus, 0.93 mm (0.36–2.01) three cm above the umbilicus, 0.21 mm (-0.53–0.98) two cm below the umbilicus; mean thickness of the linea alba 0.28 mm (0.15–0.5); mean distance between the lateral lining of the rectus muscle and the external, internal and transverse oblique muscles of respectively 1.19 (-0.99–2.82), 0.09 mm (-1.37–1.3) and 1.46 mm (-1.36–3.19) at umbilicus level. Responses to the questionnaires showed overall low values on DRI, UDI-6, IIQ-7 and Oswestry; and overall values on Baecke and SF-36 similar to the normative population. Conclusions This study provides baseline data on the normal abdominal wall anatomy as well as mean values of activity, physical function, disabilities and quality of life, in a healthy nulliparous female cohort.

Association between one-to-one midwifery care in the active phase of labour and use of pain relief and birth outcomes: A cohort of nulliparous women

ObjectiveTo investigate the association between one-to-one midwifery care and birth outcomes with pain relief as the primary outcome. Secondary outcomes include obstetric and neonatal outcomes, such as mode of birth and Apgar score. DesignA cohort study of women originally included in a cluster randomised trial. Setting and participantsThe analysis is based on data from The Labour Progression Study (LaPS), a cluster randomised controlled trial (RCT) including 7,277 women, conducted in fourteen obstetric units in Norway, between 2014 and 2017. The participants were nulliparous with a singleton full-term foetus in a cephalic presentation and spontaneous onset of labour. In this cohort, 7,103 women with information about on one-to-one midwifery care were included. Measurements and findingsLogistic regression analysis show that nulliparous women receiving one-to-one midwifery care in the active phase of labour are less likely to have an epidural analgesia, adjusted OR of 0.81 (95% CI 0.72,0.91), less likely to be given nitrous oxide, adjusted OR of 0.77 (95% CI 0.69,0.85), and they more often received massages, adjusted OR of 1.76 (95% CI 1.47,2.11), compared with women not receiving one-to-one midwifery care. Descriptive analyses show that women receiving one-to-one midwifery care in the active phase of labour are less likely to have a caesarean section (5.8% vs. 7.2%) and they are less likely to have an operative vaginal birth (16.5% vs. 23.7%). No significant differences were observed between the groups in terms of low Apgar scores at five minutes. Key conclusionsWe found that one-to-one midwifery care in the active phase of labour may be associated with birth outcomes, including decreased use of epidural analgesia and a decreased rate of caesarean sections and operative vaginal birth. Implications for practiceThe results of this study could encourage midwives to be present during the active phase of labour to promote physiological birth.

Pelvic organ prolapse following hysterectomy on benign indication: a nationwide, nulliparous cohort study

Hysterectomy is commonly performed and may increase the risk of pelvic organ prolapse. Previous studies in parous women have shown an increased risk of pelvic organ prolapse surgery after hysterectomy. Parity is a strong risk factor for pelvic organ prolapse and may confuse the true relation between hysterectomy and pelvic organ prolapse. This study aimed to investigate whether hysterectomy performed for benign conditions other than pelvic organ prolapse leads to an increased risk of pelvic organ prolapse surgery in a cohort of nulliparous women. We conducted a historical matched cohort study based on a nationwide population of nulliparous women born in 1947 to 2000 and living in Denmark during 1977 to 2018 (N=549,197). The data were obtained from the Danish Civil Registration System, the Danish National Patient Registry, the Fertility Register, and Statistics Denmark. Women who had a hysterectomy performed in 1977 to 2018 were included in the study (n=9535). For each of these women we randomly retrieved five nonhysterectomized women matched on age and calendar year to constitute the reference group (n=47,370). Cox proportional hazard regression analyses were performed to compare the risk of pelvic organ prolapse surgery in the 2 groups of women. The study included 56,905 women whom we observed for up to 42 years, entailing 809,435 person-years in risk. Overall, 9535 women who underwent a hysterectomy were matched individually with 47,370 reference women. Subsequently, a total of 29 women (30.4%) who underwent a hysterectomy and 85 reference women (17.9%) had a pelvic organ prolapse surgery performed, corresponding to incidence rates of 20.5 and 12.7 per 100,000 risk years, respectively. In addition, the risk of pelvic organ prolapse surgery increased by 60% in women who underwent a hysterectomy compared with women in the reference group (crude hazard ratio, 1.6; 95% confidence interval, 1.0-2.5; P=.04; adjusted hazard ratio, 1.6; 95% confidence interval, 1.0-2.5; P=.04). After the exclusion of women who underwent vaginal hysterectomy and their matches, the results were significantly the same (crude hazard ratio, 1.5; 95% confidence interval, 1.0-2.4; P=.05). Furthermore, we found higher rates of pelvic organ prolapse surgery in women who had a subtotal hysterectomy, total hysterectomy, or vaginal and laparoscopic-assisted vaginal hysterectomies than in women in the reference group. Hysterectomy increased the risk of pelvic organ prolapse surgery for nulliparous women by 60%. Previous studies of multiparous women have similarly shown an increased risk of prolapse after hysterectomy. As the most common risk factor for pelvic organ prolapse-vaginal birth-was not included and women were >72 years of age in this study, the numbers of pelvic organ prolapse surgeries were low. Despite the low absolute risk of pelvic organ prolapse surgery in nulliparous women, they were important in investigating the association between hysterectomy and pelvic organ prolapse, excluding vaginal birth, which is the most common risk factor for pelvic organ prolapse. As this cohort study of nulliparous women found an increased risk of pelvic organ prolapse surgery after hysterectomy, it is implied that the uterus per se protects against pelvic organ prolapse. As such, gynecologists should be aware of the risks associated with hysterectomy, and alternative uterus-sparing treatments should be considered when possible. Furthermore, women should be informed about the risks before being offered a hysterectomy.

Is Exposure to Intrapartum Prostaglandins for Labor Induction Associated with a Lower Incidence of Neonatal Respiratory Distress Syndrome?

Respiratory distress syndrome (RDS) is implicated in 30% of neonatal deaths. Since prostaglandins promote surfactant secretion and labor is associated with a lower risk of RDS in term neonates, it is plausible that synthetic prostaglandin (sPG) exposure is associated with a lower risk of RDS. Thus, we evaluated the association between sPG exposure and RDS in neonates born after the induction of labor (IOL). Secondary analysis of women with singleton pregnancies undergoing IOL at 340/7 to 420/7 weeks in the nuMoM2b study, a multicenter prospective cohort of nulliparous women. RDS rates and secondary neonatal outcomes in neonates with intrapartum sPG exposure were compared with those who had IOL with non-sPG methods (e.g., balloon catheter, amniotomy, oxytocin, and laminaria). Logistic regression models estimated the association of sPG with RDS and with secondary outcomes after adjustment for clinical and demographic factors (including gestational age). A sensitivity analysis was performed in which analysis was restricted to those with an admission cervical dilation ≤2 cm. Of 10,038 women in the total cohort, 3,071 met inclusion criteria; 1,444 were exposed and 1,627 were unexposed to sPGs. Antenatal corticosteroid exposure rates were low (3.0%) and similar between groups. In univariable analysis, neonates with sPG exposure had higher rates of RDS (3.2 vs. 2.0%, odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.01-2.50). This relationship was similar by gestational age at delivery (term vs. preterm, interaction p = 0.14). After adjustment, the association between sPG and RDS was no longer significant (adjusted odds ratio: 1.4, 95% CI: 0.9-2.3). When analysis was restricted to subjects with admission cervical dilation of ≤2 cm, there was also no association between sPG exposure and RDS. In pregnancies between 34 and 42 weeks of gestation, exposure to sPG for cervical ripening or labor induction was not associated with newborn RDS. · RDS is implicated in 30% of neonatal deaths.. · sPG exposure was not associated with RDS.. · Avoiding preterm birth remains crucial in RDS prevention..

Incidence of and Risk Factors for Failed Induction of Labor Using a Contemporary Definition.

To estimate the incidence of failed induction of labor and the associated patient risk factors. We performed a case-control study from a cohort of nulliparous women who delivered between 39 and 41 weeks of gestation after an induction of labor in one of seven hospitals. Cases of failed induction were defined using the Obstetric Care Consensus criteria (ie, cesarean delivery performed in early labor [less than 6 cm dilatation] after at least 12 hours of oxytocin administration from membrane rupture). For each case of failed induction, the next four women who did not meet the criteria for failed induction of labor were selected for the control group, matched by hospital. We identified characteristics associated with failed induction of labor using a multivariable conditional logistic regression that was constructed with backward stepwise method for variable selection. Across the hospitals, 4,123 of 10,175 nulliparous women were induced (40.5%), of whom 82 had a failed induction of labor (2.0%). A total of 328 women were selected for the matched control group. Baseline characteristics were similar between the groups. Compared with women in the control group, women with a failed induction were more likely to have a delivery body mass index (BMI) of 40 or higher (28.0 vs 8.2%, P<.001), shorter height (mean 63.9 vs 64.8 inches, P=.01), and closed cervix on admission (41.5 vs 24.1%, P=.002). Factors significantly associated with induction failure in the multivariable model included: 1) delivery BMI (adjusted odds ratio [aOR] 7.93, 95% CI 3.48-18.09, for BMI 40 or higher relative to BMI lower than 30, 2) height in inches (aOR 0.89, 95% CI 0.80-0.98), and 3) number of centimeters dilated on admission 2 or more (aOR 0.30, 95% CI 0.14-0.65). Failed induction of labor occurs infrequently. Risk factors include shorter height, BMI 40 or higher, and cervical dilatation of less than 2 cm on admission. Even so, most women with these risk factors will not experience failed labor induction.

The impact of active delivery of the anterior arm during vacuum-assisted vaginal delivery on perineal tears: a clinical practice evaluation

Objective: Our purpose was to evaluate the impact of active delivery of the anterior arm with Couder’s Maneuver (CM) during vacuum-assisted vaginal delivery (VAVD) on perineal tears. This maneuver can be beneficial because it has the advantage of reducing fetal biacromial diameter.Methods: This monocentric retrospective study compared two non-concurrent cohorts of nulliparous women before and after implementation of a systematic CM during VAVD: Cohort 1 from 1 January to 31 December 2006 without CM and Cohort 2 from 1 January to 31 December 2016 with systematic CM. This study reviewed all births during these two periods. All live-born singleton pregnancies where VAVD occurred after 37 weeks of gestation were included. The principal endpoint was the type of perineal tear.Results: In total, there were 179 VAVD in the Cohort 1 and 267 VAVD in the Cohort 2. In the Cohort 2, 233 VAVD (87.3%) were performed with systematic CM. No episiotomy was performed in both cohorts. There was a significant decrease in the rate of second-degree perineal tears between the two cohorts (42.4 versus 15%, p < .001) and a significant increase in the rate of intact perineum (34.1 versus 54.7%, p < .001). There was no influence of CM on the rate of obstetrical anal sphincter injury (3.9 versus 2.6%, p = .44).Conclusions: Practicing this maneuver could improve the perineal prognosis during VAVD in nulliparous women.

Body mass index and the risk of hypertensive disorders of pregnancy: the great obstetrical syndromes (GOS) study

Objective To estimate the association between first-trimester body mass index (BMI) and the different types of hypertensive disorders of pregnancy (HDP). Methods A prospective cohort of nulliparous women recruited at 11–13 weeks. Height and weight were measured and BMI was reported as binary (more or less than 30 kg/m2), categorical (World Health Organization classification), and continuous variables. Participants were followed for development of any HDP, including preeclampsia and preterm preeclampsia. Receiver operating characteristic curves and their area under the curve (AUC) were used along with multivariate logistic regressions to develop predictive models combining BMI with other maternal characteristics. Results We recruited 4683 eligible participants including 645 (14%) affected by obesity. Obesity was associated with greater risks of HDP (22.5 versus 8.5%, p < .0001), preeclampsia (10.2 versus 4.3%, p < .0001), and preterm preeclampsia (1.6 versus 0.6%, p = .006). BMI categories (AUC: 0.65; 95%CI: 0.56–0.74) and BMI combined with maternal characteristics (AUC: 0.76; 95%CI: 0.69–0.83) were better predictors of preterm preeclampsia than BMI as binary variable (AUC: 0.58; 95%CI: 0.50–0.66). Conclusions Obesity and BMI are associated with the risk of all types of HDP. Optimal prediction of preterm preeclampsia is achieved by using BMI as a continuous variable combined with other maternal characteristics.

P 35 First trimester maternal serum neutrophil gelatinase-associated lipocalin (NGAL) in prediction of preeclampsia in nulliparous women

Introduction Neutrophil gelatinase-associated lipocalin (NGAL) is a 25-kDA glycoprotein and a marker of endothelial damage. Pregnancies complicated by preeclampsia (PE) are characterized by placental insufficiency and endothelial dysfunction. Its speculated that NGAL is elevated in pregnancies with PE. Objectives To establish first trimester maternal serum NGAL concentration in normal pregnancies and in pregnancies complicated by PE. Furthermore, to evaluate the screening performance for PE. Material and methods Case-cohort study based on a cohort of nulliparous women consecutively enrolled into the first trimester combined screening programme for trisomy 21. The NGAL concentration was measured in cases with late-onset (GA ⩾ 37 weeks + 0 days) PE (n = 213), early-onset (GA Results Serum samples were drawn at a median gestational age of 11 weeks + 0 days (range 8 weeks + 1 day – 13 weeks + 5 days). The NGAL concentration was not correlated with gestational age (r = 0.07, p = 0.14), but correlated very weakly with maternal weight (r = 0.12, p = 0.01). The median NGAL concentration in controls was 68.0 ng/mL (IQR 38.5 ng/mL). The NGAL concentration was significantly elevated in cases with early-onset PE (median 78.0 ng/mL, IQR 50 ng/mL, p = 0.04). In contrast, no significant change was found in cases with late-onset PE (median 69.0 ng/mL, IQR 49.5 ng/mL, p = 0.07). The detection rate was 15% for a 10% false positive rate in screening for early-onset PE. The area under the ROC curve was 0.59. Conclusion First trimester maternal serum NGAL is not correlated with gestational age. NGAL is significantly elevated in pregnancies that develop early-onset PE. In contrast, NGAL is unchanged in cases with late-onset PE. Screening performance for early-onset PE is poor.

Trial of labour after caesarean (TOLAC) is associated with increased risk for instrumental delivery

We compared the rates of instrumental delivery in a cohort of nulliparous women at term (n = 19,416), to primiparous women who attempted labour after prior caesarean (TOLAC) (n = 1747). The rate of instrumental deliveries was higher in the TOLAC group compared to nulliparous gravidas (17.3 vs. 15% respectively, p = 0.001). The difference was more prominent for women who eventually had successful vaginal delivery (TOLAC: 23.9% vs. controls: 17.1%, p < 0.0001 respectively). Based on our results, previous caesarean whether urgent or elective was associated with an increased risk of instrumental delivery in the subsequent pregnancy.

46 Prediction of preeclampsia using the sFlt-1:PLGF ratio: A prospective cohort study of unselected nulliparous women

Background Preeclampsia remains a significant cause of maternal and perinatal morbidity. A recent study has suggested that the ratio of soluble fms-like tyrosine kinase 1 (sFlt-1) to placental growth factor (PlGF) in maternal serum provides clinically useful prediction of risk in women with suspected preeclampsia. Methods We sought to assess a blinded sFlt-1:PlGF ratio as a screening test for preeclampsia in a prospective cohort of unselected nulliparous women, using pre-defined thresholds for screen positive. We studied blood samples from 4512 women recruited to the Pregnancy Outcome Prediction study (see Lancet 2015; 386:2089–2097). Maternal serum levels of sFlt-1 and PlGF were measured using Roche Elecsys assays on the electro-chemiluminescence immunoassay platform, Cobas e411 (Roche Diagnostics). Preeclampsia was defined using the 2013 ACOG system, blind to the results of the biochemical assays. High risk of preeclampsia was defined as either maternal characteristics (using the UK’s National Institute for Health and Care Excellence Guideline) or elevated 20 uterine artery Doppler (mean pulsatility index >90th percentile) at around 20 weeks of gestational age. The primary outcomes were preeclampsia resulting in preterm birth (28 weeks of gestational age [wkGA] measurement, n = 3989) or preeclampsia with severe features (36wkGA measurement, n = 3776). Results Women with an sFlt-1:PlGF ratio >38 at 28wkGA had an incidence of preeclampsia leading to preterm delivery of 32%. The positive predictive value was similar in low and high risk women (33% vs 31%, respectively, P = 0.91). Women with an sFlt-1:PlGF ratio>38 at 36wkGA had an incidence of preeclampsia with severe features of 10%. The positive predictive value was 20% in high risk women and 6.4% in low risk women. Among women with no prior risk factors, an sFlt-1:PlGF ratio 99%). At 36wkGA, 70 women had an sFlt1:PlGF ratio >110 and 21 (30%) developed preeclampsia with severe features. We then analysed a composite definition of screen positive at 36wkGA, namely, an sFlt-1:PlGF ratio of >110 or an sFlt-1:PlGF ratio >38 plus maternal risk factors. A total of 195 (5.2%) women screened positive by this definition: 41 (21%) of them developed pre-eclampsia with severe features and a further 43 (23%) developed preeclampsia without severe features. Conclusions The sFlt-1:PlGF ratio provided clinically useful prediction of the risk of the most important manifestations of preeclampsia in a cohort of nulliparous women. Screening women at 36wkGA could be used to target monitoring and induction of labour prior to development of disease, or its most severe manifestations.

Assisted conception, maternal age and breastfeeding: an Australian cohort study

To establish the relationships between age, mode of conception and breastfeeding. Consecutive cohorts of nulliparous women >25 weeks pregnant who had conceived through ART (ARTC) or spontaneously (SC) in three age groups ≤30, 31-36 and ≥37 years were recruited. Data were obtained via telephone interviews and postal questionnaires in late pregnancy and 4 months postpartum. Sociodemographic characteristics, reproductive health, birth and breastfeeding experiences were assessed by study-specific questions. Self-rated general health and symptoms of depression and anxiety were assessed with standardized psychometric instruments. Main outcomes were exclusive breastfeeding at discharge from maternity hospital and 4 months postpartum. Of 1179 eligible women, 791 (67%) participated; 549 (93%) had singleton infants, provided complete data and were included in analyses. Overall, 37.2% of participants aged ≤30, 33% aged 31-36 and 55.1% aged ≥37 years experienced Caesarean births. Regardless of age, compared with the SC group, ARTC women had twice the rate of Caesareans prior to labour. Controlling for other factors, exclusive breastfeeding rates at hospital discharge and 4 months postpartum were lowest amongst ARTC women who experienced Caesarean prior to labour (p < .001). Independent of age, assisted conception increases the risk conferred by Caesarean birth to breastfeeding initiation and maintenance.

Risk of First-stage and Second-stage Cesarean Delivery by Maternal Body Mass Index Among Nulliparous Women in Labor at Term

OBJECTIVE:To estimate in a cohort of nulliparous women in labor at term whether cesarean delivery rates are increased in first and second stages of labor in overweight and obese women and whether being overweight or obese is an independent risk factor for cesarean delivery.METHODS:Nulliparous women

Risk of First-Stage and Second-Stage Cesarean Delivery by Maternal Body Mass Index Among Nulliparous Women in Labor at Term

To estimate in a cohort of nulliparous women in labor at term whether cesarean delivery rates are increased in first and second stages of labor in overweight and obese women and whether being overweight or obese is an independent risk factor for cesarean delivery. Nulliparous women recruited to the prospective Screening for Pregnancy Endpoints study who went into labor after 37 weeks of gestation were categorized according to ethnicity-specific body mass index (BMI) criteria as normal, overweight, or obese. Normal BMI was the referent. Multivariable analysis, adjusting for known confounders for obesity and cesarean delivery, was performed to estimate if being overweight or obese was associated with an increased risk of cesarean in labor (all cesarean deliveries and in first stage of labor). Of 2,629 participants, 1,416 (54%) had normal BMIs, 773 (29%) were overweight, and 440 (17%) were obese. First-stage cesarean delivery was increased in overweight (n=149 [19%]) and obese (n=137 [31%]) women compared with normal-weight women (n=181 [13%; P<.001), whereas second-stage cesarean delivery was similar (normal BMI 76 [6.2%], overweight 45 [7.2%], obese 23 [7.6%], P=.87). Being overweight or obese was an independent risk factor for all cesarean deliveries in labor with adjusted odds ratio (OR) of 1.34 (95% confidence interval [CI] 1.07-1.67) and 2.51 (95% CI 1.94-3.25), respectively. Similarly, being overweight (adjusted OR 1.39; 95% CI 1.09-1.79) or obese (adjusted OR 2.89; 95% CI 2.19-3.80) was associated with increased cesarean delivery during the first stage. Risks of cesarean delivery were similar regardless of whether ethnicity-specific or World Health Organization (WHO) BMI criteria were used. Among nulliparous women in labor at term, being overweight or obese by either WHO or ethnicity-specific BMI criteria is an independent risk factor for cesarean delivery in the first stage but not the second stage of labor. Australian New Zealand Clinical Trials Registry, www.anzctr.org.au, ACTRN12607000551493.

Factors Associated With Cesarean Delivery in Nulliparous Women With Type 1 Diabetes

To identify factors associated with cesarean delivery in nulliparous women with type 1 diabetes mellitus. We performed a nested case-control study within a cohort of nulliparous women with type 1 diabetes mellitus. Independent factors and odds ratios were identified by logistic regression. Among 209 women, a cesarean delivery was performed without labor in 94 women (45%). Gestational weight gain higher than 15 kg (39% compared with 23%; odds ratio [OR], 2.2; 95% confidence interval [CI], 1.1-4.5) and suspected macrosomia (79% compared with 21%; OR, 13.1; 95% CI, 5.3-32.2) were independently associated with cesarean delivery without labor. Among 115 women who underwent a trial of labor, 54 (47%) had a cesarean delivery. Prepregnancy body mass index more than 25 kg/m2 (84% compared with 39%; OR, 7.5; 95% CI, 1.9-29.4) and Bishop score 3 or lower (66% compared with 25%; OR, 5.9; 95% CI, 2.2-16.1) were independently associated with cesarean delivery in labor. Preconception care, presence of a nephropathy, hemoglobin A1C levels during pregnancy, preeclampsia, and preterm delivery were not associated with cesarean delivery. The rates of wound infection and endometritis were 0.7% and 3%, respectively. The rate of cesarean delivery in nulliparous women with type 1 diabetes mellitus is very high. Prepregnancy body weight, gestational weight gain, and accuracy of the prediction of fetal macrosomia are potentially modifiable risk factors for cesarean delivery.

Adhesion molecules changes at 20 gestation weeks in pregnancies complicated by preeclampsia

Objectives To examine soluble E-selectin, L-selectin, P-selectin, ICAM-1, and VCAM-1 levels in normotensive and preeclamptic pregnancies. To determine cut-offs useful for preeclampsia early detection. Study design A cohort of nulliparous women was recruited at family medicine clinics in Mexico City. Preeclampsia developed in 75 patients; 125 normotensive controls were matched. Adhesion molecules were assessed in serum obtained at 20 gestation weeks and in third trimester pregnancies. Predictive values and odds ratios for preeclampsia development were calculated with the 20 gestation week results. Threshold values were selected based on ROC curves values. Results In women with subsequent preeclampsia, sL-selectin and sVCAM-1 concentrations were significantly lower, whereas sE-selectin, sP-selectin and sICAM-1 levels were significantly higher, compared with controls at mid-pregnancy ( p < 0.05). The odds ratio for low sL-selectin was 25.6 (95% CI, 8.9–73.5; cut-off, 1414 ng/ml). The sensitivity, specificity, and positive and negative predictive values of low sL-selectin for preeclampsia development were 84, 90, 39, and 98%, respectively, whereas its sensitivity, specificity, and positive and negative predictive values for severe preeclampsia development (cut-off, 1210 ng/ml) were 100, 98, 60, and 100%, respectively. Conclusions Early enhanced activation of endothelial cells, platelets and leukocytes seem to be present in preeclamptic patients, especially in those that develop severe preeclampsia. Low sL-selectin levels at 20 gestation weeks may be an indicator of preeclampsia development.

Prostacyclin/thromboxane early changes in pregnancies that are complicated by preeclampsia

Objective: The purpose of this study was to examine 6-keto-prostaglandin F1α and thromboxane B2 plasma levels throughout normotensive and preeclamptic pregnancies and to analyze the predictive values of these quantifications for the detection of preeclampsia during the second trimester of pregnancy. Study Design: Blood samples were collected from 30 healthy, nonpregnant women and at 4-week intervals from a cohort of nulliparous women who were recruited before 16 weeks of gestation. Preeclampsia developed in 26 patients; 52 normotensive control subjects were matched from the same cohort. The 6-keto-prostaglandin F1α and thromboxane B2 were assayed by radioimmunoassay. Trends were compared between pregnancy groups and with the nonpregnant women. Predictive values were determined with the second-trimester assessments. Results: The 6-keto-prostaglandin F1α/thromboxane B2 ratio decreased throughout pregnancy in women with preeclampsia; there were no significant changes in normotensive women. We found higher thromboxane B2 levels within the group with preeclampsia during the first gestational trimester (preeclampsia, 188 ± 17 pg/mL; control, 119 ± 4.8 pg/mL [mean ± SEM]; P =.001). During the third trimester, patients with preeclampsia had lower 6-keto-prostaglandin F1α levels than did control subjects (preeclampsia, 191 ± 9.8 pg/mL; control, 288 ± 10 pg/mL; P =.001). The 6-keto-prostaglandin F1α/thromboxane B2 ratio was suitable to calculate predictive values; the best cutoff point and time interval were 3.0 and 22 to 26 weeks of gestation, respectively. Sensitivity, specificity, and positive and negative predictive values were 88%, 97%, 69%, and 99%, respectively; the odds ratio was 14.6 (95% CI, 6.9-30.4). Conclusion: The prostacyclin/thromboxane ratio favored vasoconstriction early in gestation in women in whom preeclampsia developed. A 6-keto-prostaglandin F1α/thromboxane B2 ratio of ≤3.0 at 22 to 26 weeks of gestation had a high predictive value for the development of preeclampsia.

Effect of one interval vaginal delivery on the prevalence of stress urinary incontinence: a prospective cohort study.

To analyze the effect of one interval vaginal delivery on the prevalence of stress urinary incontinence amongst a cohort of nulliparous women. A cohort of 276 nulliparous women without incontinence was recruited consecutively in 1996, after they had vaginal delivery, and were followed-up for urinary incontinence in 2000. The age, obstetric variables of the 1996 delivery (mode of delivery, genital tract trauma, birth weight, epidural analgesia, episiotomy, durations of labor, postpartum urinary retention), and the presence of interval vaginal delivery during the follow-up period were recorded. The obstetric factors and the prevalence of urinary stress incontinence at follow-up were then compared between women with and without interval vaginal delivery. Logistic regression analysis was performed to test the independence of the obstetric variables in the index pregnancy and the presence of one interval vaginal delivery, with urinary stress incontinence being the dependent variable. A total of 148 (53.6%) women were followed-up. The prevalence of urinary incontinence was 28.6% in women without interval delivery and 21.1% in women with one interval delivery. There was no significant difference in the prevalence of urinary incontinence between the two groups (chi(2) test, P = 0.31). Logistic regression showed that none of the obstetric variables or the presence of one interval vaginal delivery was significantly associated with urinary incontinence. One interval vaginal delivery does not increase risk of urinary stress incontinence 4 years after the index vaginal delivery.

Nutrient intakes during pregnancy in a cohort of nulliparous women

Background: This study investigated dietary intake in a large cohort of pregnant women. There are few data available on the diets of British pregnant women, and no study has previously compared the intakes of pregnant women, from both food and all sources, with those of non‐pregnant women or with the current dietary reference values. Methods: Dietary information was collected from 774 pregnant nulliparous women in the early stages of pregnancy as part of the Prospective Study of Nutrition, Smoking and Pregnancy Outcome. Subjects completed 7‐day semiquantitative food diaries, which were converted into nutrient values using the COMP‐EAT 4 nutritional system. Results: Reference nutrient intake values were achieved by over 65% of the cohort for the nutrients investigated, except for vitamin D, folate, iron and selenium, where there was a considerable shortfall even after taking into account use of nutrient supplements. Conclusion: The dietary intake of the pregnant women in this study appears to be very similar to that of non‐pregnant women in the Dietary and Nutritional Survey of British Adults.