Ultrasound examination of the pelvic floor during active labor : A longitudinal cohort study

Publisher Copyright: © 2023 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).Introduction: There is limited evidence about changes in the pelvic floor during active labor. We aimed to investigate changes in hiatal dimensions during the active first stage of labor and associations with fetal descent and head position. Material and methods: We conducted a longitudinal, prospective cohort study at the National University Hospital of Iceland, from 2016 to 2018. Nulliparous women with spontaneous onset of labor, a single fetus in cephalic presentation, and gestational age ≥37 weeks were eligible. Fetal position was assessed with transabdominal ultrasound and fetal descent was measured with transperineal ultrasound. Three-dimensional volumes were acquired from transperineal scanning at the start of the active phase of labor and in late first stage or early second stage. The largest transverse hiatal diameter was measured in the plane of minimal hiatal dimensions. The levator urethral gap was measured as the distance between the center of the urethra and the levator insertion using tomographic ultrasound imaging. Measurements of the levator urethral gap were made in the plane of minimal hiatal dimensions and 2.5 and 5 mm cranial to this. Results: The final study population comprised 78 women. The mean transverse hiatal diameter increased 12.4% between the two examinations, from 39.4 ± 4.1 mm (±standard deviation) at the first examination to 44.3 ± 5.8 mm at the last examination (p < 0.01). We found a moderate correlation between the transverse hiatal diameter and fetal station at the last examination (r = 0.44, r2 = 0.19; p < 0.01; regression equation y = 2.71 + 0.014x), and a weak correlation between the change in transverse hiatal diameter and change in fetal station (r = 0.29; r2 = 0.08; p = 0.01; regression equation y = 0.24 + 0.012x). Levator urethral gap increased significantly in all three planes on both the left and right sides. Head position was not associated with hiatal measurements after adjusting for fetal station. Conclusions: We found a significant, but only modest, increase of the hiatal dimensions during the first stage of labor. The risk of levator ani trauma will therefore be low during this stage. The change in transverse hiatal diameter was associated with fetal descent but not with head position.Peer reviewe

Vitamin D and stress urinary incontinence in pregnancy: a cross-sectional study

Objective To assess the association between levels of vitamin D and urinary incontinence (UI) in pregnancy. Design A cross‐sectional study. Secondary analysis of a randomised controlled trial. Setting Two university hospitals in Norway. Population A total of 851 healthy, pregnant women >18 years in gestational weeks 18–22 with a singleton live fetus. Methods Data on UI were collected from a questionnaire at inclusion and serum analysis of 25‐hydroxy vitamin D (25(OH)D) was performed. Univariable and multivariable logistic regression analyses were applied to study associations between exposure and outcomes. Main outcome measures Prevalence of self‐reported UI, stress (SUI) and urge (UUI) or mixed UI. Results In total, 230/851 (27%) of the participants were vitamin D insufficient (25(OH)D <50 nmol/l) and 42% reported to have any UI. Women with 25(OH)D <50 nmol/l were more likely to report any UI (P = 0.03) and SUI (P < 0.01) compared with women with 25(OH)D ≥50 nmol/l. In a univariable logistic regression analysis, serum levels of 25(OH)D <50 nmol/l was associated with increased risk of any UI (odds ratio [OR] 1.5 with 95% CI 1.0–2.1), SUI only (OR 1.7, 95% CI 1.2–2.4), but not mixed UI or UUI only (OR 0.8, 95% CI 0.5–1.5). In a multivariable logistic regression model, serum levels of 25(OH)D <50 nmol/l were associated with a higher risk of experiencing SUI only (OR 1.5, 95% CI 1.1–2.2). Conclusions Serum 25(OH)D <50 nmol/l was associated with increased risk of any UI, and SUI in particular.publishedVersio

Does regular antenatal exercise promote exclusive breastfeeding during the first 3 months of life? Secondary analyses of a randomized controlled trial

INTRODUCTION Exclusive breastfeeding (EBF) and antenatal exercise are independently ssociated with positive short- and long-term health effects for women and their children. The aims of the study were to investigate whether antenatal exercise promotes EBF three months postpartum and further to explore factors associated with EBF at three months postpartum. METHODS This study was a follow-up of a Norwegian two-center randomized controlled trial to assess the effect of an antenatal exercise protocol. The recruited pregnant women were randomized to either a 12-week standardized antenatal exercise program with one weekly group training led by a physiotherapist and two weekly home training sessions or standard antenatal care. Women reported breastfeeding status in a questionnaire at three months postpartum. RESULTS Of the 726 women, 88% were EBF at three months postpartum. There was no significant difference in EBF rates between the intervention group (87%) and the control group (89%). EBF was positively associated with maternal education (AOR=3.4; 95% CI: 1.7–6.7) and EBF at discharge from the hospital (AOR=22.2; 95% CI: 10–49). Admission to neonatal intensive care unit was identified as a significant barrier to EBF (AOR=0.2; 95% CI: 0.1–0.4). Significantly more women in the non-EBF group had sought professional help compared to women in the EBF group (p≤0.001). CONCLUSIONS Regular physical exercise during pregnancy did not influence the exclusive breastfeeding rates at three months postpartum. Considering the health effects of exclusive breastfeeding and antenatal physical exercise, studies with follow-up periods beyond three months postpartum are warranted.publishedVersio

Study protocol: differential effects of diet and physical activity based interventions in pregnancy on maternal and fetal outcomes--individual patient data (IPD) meta-analysis and health economic evaluation.

© 2014 Ruifrok et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.BACKGROUND: Pregnant women who gain excess weight are at risk of complications during pregnancy and in the long term. Interventions based on diet and physical activity minimise gestational weight gain with varied effect on clinical outcomes. The effect of interventions on varied groups of women based on body mass index, age, ethnicity, socioeconomic status, parity, and underlying medical conditions is not clear. Our individual patient data (IPD) meta-analysis of randomised trials will assess the differential effect of diet- and physical activity-based interventions on maternal weight gain and pregnancy outcomes in clinically relevant subgroups of women. METHODS/DESIGN: Randomised trials on diet and physical activity in pregnancy will be identified by searching the following databases: MEDLINE, EMBASE, BIOSIS, LILACS, Pascal, Science Citation Index, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Health Technology Assessment Database. Primary researchers of the identified trials are invited to join the International Weight Management in Pregnancy Collaborative Network and share their individual patient data. We will reanalyse each study separately and confirm the findings with the original authors. Then, for each intervention type and outcome, we will perform as appropriate either a one-step or a two-step IPD meta-analysis to obtain summary estimates of effects and 95% confidence intervals, for all women combined and for each subgroup of interest. The primary outcomes are gestational weight gain and composite adverse maternal and fetal outcomes. The difference in effects between subgroups will be estimated and between-study heterogeneity suitably quantified and explored. The potential for publication bias and availability bias in the IPD obtained will be investigated. We will conduct a model-based economic evaluation to assess the cost effectiveness of the interventions to manage weight gain in pregnancy and undertake a value of information analysis to inform future research. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2013: CRD42013003804.This study was funded by the National Institute for Health Research (NIHR) HTA (Health Technology Assessment) UK programme 12/01

A propriedade sem registro : o contrato e aquisição da propriedade imóvel na perspectiva civil-contitucional

Orientador : Prof. Dr. Eroulths Cortiano JuniorTese (doutorado) - Universidade Federal do Paraná, Setor de Ciências Jurídicas, Programa de Pós-Graduação em Direito. Defesa: Curitiba, 12/08/2014Inclui referênciasResumo: Esta tese objetiva uma releitura da obrigatoriedade do registro nas aquisições da propriedade imóvel, a partir do reconhecimento do contrato como dotado de função social, que realiza, igualmente, a função social como liberdade de acesso aos bens. A propriedade imobiliária no Direito Civil brasileiro está qualificada como direito real, conforme o art. 1225, I, do Código Civil, e sua transferência negocial se orienta pelo sistema da separação parcial dos planos dos direitos obrigacionais e reais, o qual prevê a necessidade do contrato de transmissão (compra e venda, doação ou permuta) com posterior registro no Cartório Imobiliário, nos termos do art. 1245 e seguintes. A Constituição Federal de 1988 garante o direito de propriedade, que deve atender à sua função social, considerando-a como direito fundamental (art. 5.o, XXII e XXIII) e como princípio geral da ordem econômica (art. 170, II e III). A necessária interação entre o Direito Civil e a Constituição, sob a supremacia hierárquica desta, conduz a entender que o direito de propriedade atual, para além da literalidade do Código Civil, deve nortear-se pela sintonia entre ambos os diplomas legais, mas a partir da observação dos princípios e dos valores constitucionais. O Direito Civil-Constitucional surge, então, como uma opção de desenvolvimento do pensamento jurídico, que visa oferecer espaço de reflexão que supere a dogmática unicamente codificada, pois, com fundamento nos princípios e na axiologia constitucional, auxilia na ressignificação de institutos clássicos, como a propriedade e o contrato. O acesso à propriedade, então, pode ser considerado para além da letra da lei, o que permite relevar o registro, com a funcionalização do contrato que, a partir de sua teleologia, da solidariedade, da alteridade e da boa-fé, pode ser o elemento constitutivo da propriedade, com base no caso concreto. A aplicação direta e imediata da Constituição nas relações interprivadas favorece a ressignificação do contrato, que alçará significado de título suficiente para garantir o direito à propriedade (acesso). A complexidade e a pluralidade das relações sociais conduzem a uma transição do modelo abstrato e individualista da propriedade para o da propriedade concreta, que se constrói na funcionalização como liberdade(s) com vistas à realização das necessidade da pessoa concretamente considerada.Abstract: The aim of this thesis is to re-read the mandatory registration on acquisition of immovable property, from the social function of contract's recognition, which also performs its social function as freedom of access to assets. The immovable property in the Brazilian Civil Law is qualified as a real right, according to art. 1225, I, Civil Code, and its negotiating transferring is guided by the partial separation between obligations and real rights, which predicts the registration of transmission's contract (sale, donation or exchange) with the state registration authority, according to art. 1245 and on Civil Code. The 1988 Federal Constitution guarantees the right to property, which must meet its social function, considering it as a fundamental right (art. 5, XXII and XXIII) and as a general principle of economic order (art. 170, II and III). The necessary interaction between the civil law and the Constitution, under the hierarchical supremacy of this leads to understand that the current property law, beyond its literal meaning of the Civil Code, shall be guided by the line between the two enactments, but from the observation of constitutional principles and values.The Civil-constitutional Law arises, then, as an option for legal thinking development, which aims to provide a reflection space that overcomes the consolidated dogmatic, therefore, on the basis of principles and the constitutional axiology, assists in reframing classical institutes, as property and contract. The access to the property can then be considered beyond the letter of the law, which allows to release the register, with the functionalization's contract which, from its teleology, solidarity, alterity and good faith, may be the constituent element of the property, based on the case. The direct and immediate constitutional applying in privates relations cooperate to the contract redefinition, which obtain the sufficient title to guarantee the right to property (access). The complexity and plurality of social relations lead to a transition from abstract and individualistic model of property to concrete one which is constructed on functionalization as freedom (s) to intending to accomplish persons needs concretely considered

Exercise Training in Pregnancy for obese women (ETIP): study protocol for a randomised controlled trial

<p/> <p>Background</p> <p>Both maternal pre-pregnancy obesity and excessive gestational weight gain are increasing in prevalence and associated with a number of adverse pregnancy outcomes for both mother and child. Observational studies regarding physical activity in pregnancy have found reduced weight gain in active mothers, as well as reduced risk of adverse pregnancy outcomes. There is however a lack of high quality, randomized controlled trials on the effects of regular exercise training in pregnancy, especially those with a pre-pregnancy body mass index (BMI) at or above 30 kg/m².</p> <p>Methods</p> <p>We are conducting a randomised, controlled trial in Norway with two parallel arms; one intervention group and one control group. We will enroll 150 previously sedentary, pregnant women with a pre-pregnancy BMI at or above 30 kg/m². The intervention group will meet for organized exercise training three times per week, starting in gestation week 14 (range 12-16). The control group will get standard antenatal care. The main outcome measure will be weight gain from baseline to delivery. Among the secondary outcome measures are changes in exercise capacity, endothelial function, physical activity level, body composition, serum markers of cardiovascular risk, incontinence, lumbopelvic pain and cardiac function from baseline to gestation week 37 (range 36-38). Offspring outcome measures include anthropometric variables at birth, Apgar score, as well as serum markers of inflammation and metabolism in cord blood.</p> <p>Discussion</p> <p>The results of this trial will provide knowledge about effects of regular exercise training in previously sedentary, obese pregnant women. If the program proves effective in reducing gestational weight gain and adverse pregnancy outcomes, such programs should be considered as part of routine pregnancy care for obese women.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov: <a href="http://www.clinicaltrials.gov/ct2/show/NCT01243554">NCT01243554</a></p

Erratum to: Study protocol: differential effects of diet and physical activity based interventions in pregnancy on maternal and fetal outcomes: individual patient data (IPD) meta-analysis and health economic evaluation

After publication of this work [1], we noted that we inadvertently failed to include the complete list of all coauthors and that sample sizes of some of the trials listed in Table two were incorrect

External validation of prognostic models predicting pre-eclampsia : individual participant data meta-analysis

Abstract Background Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk during pregnancy is required to plan management. Although there are many published prediction models for pre-eclampsia, few have been validated in external data. Our objective was to externally validate published prediction models for pre-eclampsia using individual participant data (IPD) from UK studies, to evaluate whether any of the models can accurately predict the condition when used within the UK healthcare setting. Methods IPD from 11 UK cohort studies (217,415 pregnant women) within the International Prediction of Pregnancy Complications (IPPIC) pre-eclampsia network contributed to external validation of published prediction models, identified by systematic review. Cohorts that measured all predictor variables in at least one of the identified models and reported pre-eclampsia as an outcome were included for validation. We reported the model predictive performance as discrimination (C-statistic), calibration (calibration plots, calibration slope, calibration-in-the-large), and net benefit. Performance measures were estimated separately in each available study and then, where possible, combined across studies in a random-effects meta-analysis. Results Of 131 published models, 67 provided the full model equation and 24 could be validated in 11 UK cohorts. Most of the models showed modest discrimination with summary C-statistics between 0.6 and 0.7. The calibration of the predicted compared to observed risk was generally poor for most models with observed calibration slopes less than 1, indicating that predictions were generally too extreme, although confidence intervals were wide. There was large between-study heterogeneity in each model’s calibration-in-the-large, suggesting poor calibration of the predicted overall risk across populations. In a subset of models, the net benefit of using the models to inform clinical decisions appeared small and limited to probability thresholds between 5 and 7%. Conclusions The evaluated models had modest predictive performance, with key limitations such as poor calibration (likely due to overfitting in the original development datasets), substantial heterogeneity, and small net benefit across settings. The evidence to support the use of these prediction models for pre-eclampsia in clinical decision-making is limited. Any models that we could not validate should be examined in terms of their predictive performance, net benefit, and heterogeneity across multiple UK settings before consideration for use in practice. Trial registration PROSPERO ID: CRD42015029349