Istukan ennenaikainen irtoaminen : riskitekijät ja biokemialliset merkkiaineet

Placental abruption, one of the most significant causes of perinatal mortality and maternal morbidity, occurs in 0.5-1% of pregnancies. Its etiology is unknown, but defective trophoblastic invasion of the spiral arteries and consequent poor vascularization may play a role. The aim of this study was to define the prepregnancy risk factors of placental abruption, to define the risk factors during the index pregnancy, and to describe the clinical presentation of placental abruption. We also wanted to find a biochemical marker for predicting placental abruption early in pregnancy. Among women delivering at the University Hospital of Helsinki in 1997-2001 (n=46,742), 198 women with placental abruption and 396 control women were identified. The overall incidence of placental abruption was 0.42%. The prepregnancy risk factors were smoking (OR 1.7; 95% CI 1.1, 2.7), uterine malformation (OR 8.1; 1.7, 40), previous cesarean section (OR 1.7; 1.1, 2.8), and history of placental abruption (OR 4.5; 1.1, 18). The risk factors during the index pregnancy were maternal (adjusted OR 1.8; 95% CI 1.1, 2.9) and paternal smoking (2.2; 1.3, 3.6), use of alcohol (2.2; 1.1, 4.4), placenta previa (5.7; 1.4, 23.1), preeclampsia (2.7; 1.3, 5.6) and chorioamnionitis (3.3; 1.0, 10.0). Vaginal bleeding (70%), abdominal pain (51%), bloody amniotic fluid (50%) and fetal heart rate abnormalities (69%) were the most common clinical manifestations of placental abruption. Retroplacental blood clot was seen by ultrasound in 15% of the cases. Neither bleeding nor pain was present in 19% of the cases. Overall, 59% went into preterm labor (OR 12.9; 95% CI 8.3, 19.8), and 91% were delivered by cesarean section (34.7; 20.0, 60.1). Of the newborns, 25% were growth restricted. The perinatal mortality rate was 9.2% (OR 10.1; 95% CI 3.4, 30.1). We then tested selected biochemical markers for prediction of placental abruption. The median of the maternal serum alpha-fetoprotein (MSAFP) multiples of median (MoM) (1.21) was significantly higher in the abruption group (n=57) than in the control group (n=108) (1.07) (p=0.004) at 15-16 gestational weeks. In multivariate analysis, elevated MSAFP remained as an independent risk factor for placental abruption, adjusting for parity ≥ 3, smoking, previous placental abruption, preeclampsia, bleeding in II or III trimester, and placenta previa. MSAFP ≥ 1.5 MoM had a sensitivity of 29% and a false positive rate of 10%. The levels of the maternal serum free beta human chorionic gonadotrophin MoM did not differ between the cases and the controls. None of the angiogenic factors (soluble endoglin, soluble fms-like tyrosine kinase 1, or placental growth factor) showed any difference between the cases (n=42) and the controls (n=50) in the second trimester. The levels of C-reactive protein (CRP) showed no difference between the cases (n=181) and the controls (n=261) (median 2.35 mg/l [interquartile range {IQR} 1.09-5.93] versus 2.28 mg/l [IQR 0.92-5.01], not significant) when tested in the first trimester (mean 10.4 gestational weeks). Chlamydia pneumoniae specific immunoglobulin G (IgG) and immunoglobulin A (IgA) as well as C. trachomatis specific IgG, IgA and chlamydial heat-shock protein 60 antibody rates were similar between the groups. In conclusion, although univariate analysis identified many prepregnancy risk factors for placental abruption, only smoking, uterine malformation, previous cesarean section and history of placental abruption remained significant by multivariate analysis. During the index pregnancy maternal alcohol consumption and smoking and smoking by the partner turned out to be the major independent risk factors for placental abruption. Smoking by both partners multiplied the risk. The liberal use of ultrasound examination contributed little to the management of women with placental abruption. Although second-trimester MSAFP levels were higher in women with subsequent placental abruption, clinical usefulness of this test is limited due to low sensitivity and high false positive rate. Similarly, angiogenic factors in early second trimester, or CRP levels, or chlamydial antibodies in the first trimester failed to predict placental abruption.Istukan ennenaikaisella irtoamisella (ablaatio) tarkoitetaan istukan täydellistä tai osittaista irtoamista ennen lapsen syntymää. Ablaation esiintyvyys on noin 0.5-1 % raskauksista. Vaikka kysymyksessä on harvinainen raskaushäiriö, ablaatio aiheuttaa jopa 30 % kaikista perinaataalikuolemista (=sikiön kohtukuolemista ja alle viikon ikäisten vastasyntyneiden kuolemista) ja 10 % kaikista ennenaikaisista synnytyksistä. Kyseessä on siis merkittävä raskauskomplikaatio. Ablaation syy on epäselvä, mutta on mahdollista, että istukka on kiinnittynyt jo raskauden alussa liian pinnallisesti altistaen ennenaikaiselle irtoamiselle. Tähän voi olla vaikuttamassa äidin immuunisäätelyn häiriintyminen. Tämän tutkimuksen tarkoituksena oli selvittää, mitkä raskautta edeltävät ja raskaudenaikaiset tekijät ennustavat ablaatiota ja kuvata ablaation kliinisiä löydöksiä. Halusimme myös selvittää voidaanko ablaatiota ennustaa ensimmäisen tai toisen raskauskolmanneksen verinäytteistä biokemiallisilla merkkiaineilla. Helsingin Naistenklinikalla ja Kätilöopiston sairaalassa vuosina 1997-2001 synnyttäneiden 46 742 naisen joukosta etsimme kaikki 198 naista, joilla raskausaikana oli todettu ablaatio. Tapauksille etsimme kaksi samaan aikaan synnyttänyttä verrokkia, joilla ei ollut ablaatiota, yhteensä 396. Ablaation ilmaantuvuus oli 0.42 %. Löysimme lukuisia ablaatiolle altistavia raskautta edeltäviä riskitekijöitä, joista monimuuttuja-analyysin jälkeen merkittäviä olivat tupakointi, kohdun epämuodostuma, aiempi keisarileikkaus ja aiemmin sairastettu ablaatio. Raskauden aikaisia itsenäisiä riskitekijöitä olivat sekä äidin että isän tupakointi, alkoholin käyttö, etinen istukka, raskausmyrkytys ja istukan ja sikiökalvojen tulehdus. Ablaation tavallisimmat oireet olivat vuoto (70%), vatsakipu (51 %), verinen lapsivesi (50 %) ja sikiön sykekäyrän muutokset (69 %). 19 %:lla tapauksista ei esiintynyt vuotoa tai vatsakipua. Istukantakainen verihyytymä nähtiin ultraäänitutkimuksessa ennen synnytystä 15 %:lla. Ennenaikaisena eli ennen 37. raskausviikkoa syntyi 59% lapsista ja heistä 25 %:lla todettiin kasvuhäiriö. Keisarileikkauksella lapsista syntyi 91%. Perinataalikuolleisuus oli 9,2 %. 15-16 raskausviikon sikiöseulontanäytteistä analysoimme alfa-fetoproteiini (AFP) ja beta human koriongonadotropiini (β-hCG) tulokset. Ablaatiotapauksilla AFP oli merkittävästi korkeampi kuin verrokeilla jääden monimuuttuja-analyysissä ablaation itsenäiseksi ennustekijäksi. AFP-testi ei kuitenkaan ollut riittävän herkkä ablaation seulontaan. β-hCG:n pitoisuudet eivät eronneet tapausten ja verrokkien välillä. Seeruminäytteistä tutkimme seuraavaksi verisuonikasvutekijöitä (liukoinen endogliini, liukoinen fms-like tyrosiinikinaasi ja istukan kasvutekijä). Eroja näiden merkkiaineiden pitoisuuksissa tapausten ja verrokien välillä toisessa raskauskolmanneksessa ei todettu. Alkuraskauden äitiysneuvolaseeruminäytteistä tutkimme yhteistyössä Oulun Kansanterveyslaitoksen kanssa herkän C-reaktiivisen proteiinin (CRP) ja Chlamydia trachomatis- ja C. pneumoniae- vasta-aineet. Näidenkään tulehdusta mittaavien merkkiaineiden tasot eivät eronneet toisistaan. Yhteenvetona voidaan sanoa, että ablaatiolle tunnetaan lukuisia riskitekijöitä, joista raskautta edeltävinä merkittäviä ovat tupakointi, kohdun epämuodostuma, aiempi keisarileikkaus ja aiempi ablaatio. Sekä äidin että isän raskauden aikainen tupakointi ovat itsenäisiä ablaation riskitekijöitä ja kaksinkertaistavat tämän raskauskomplikaation riskin. Mikäli molemmat puolisot tupakoivat riski on lähes viisinkertainen. Näin ollen ablaatiota voidaan helposti ehkäistä tupakoinnin lopettamiseen tähtäävällä terveyskasvatuksella. Klassisina oireina ablaatiossa pidetään veristä vuotoa ja vatsakipua, mutta nämä oireet puuttuivat 19 %:lta. Ultraäänen käytöllä ei ole suurtakaan merkitystä tämän raskauskomplikaation diagnostiikassa. Perinataalikuolleisuus on edelleen korkea, vaikka se viime vuosikymmeninä onkin laskenut keskoshoidon tehostuttua. Kuolleisuuteen vaikuttaa ennenkaikkea ennenaikaisuus mutta myös sikiön kasvun häiriintyminen. Vaikka AFP-tasot olivat ablaatioon sairastuneilla naisilla korkeammat jo toisen raskauskolmanneksen alussa, testi ei ollut trapeeksi herkkä seulontaan. Verisuonikasvutekijöillä ei ainakaan toisen raskauskolmanneksen alussa ollut ennusarvoa. Myöskään CRP tai klamydiavasta-aineet eivät ennustaneet ablaatiota

Genetic relationships among fertility, body type traits and milk yield in Finnish Ayrshire cattle

Tämän tutkimuksen päätavoitteena oli selvittää ayrshire-rodun hedelmällisyyden, runkorakenteen ja maitotuotoksen väliset geneettiset korrelaatiot sekä laskea ominaisuuksille periytymisasteet. Aineistossa oli mukana 21 450 ayrshire-rotuista eläintä 2647 eri karjasta. Eläimet olivat syntyneet vuosien 1994 – 2005 aikana, ja olivat 1652 sonnin tyttäriä. Tutkittavia hedelmällisyysominaisuuksia olivat hiehojen siemennyskauden pituus ja siemennysten lukumäärä sekä ensikoiden lepokauden pituus. Maitotuotosominaisuudet olivat ensimmäisen kerran poikineiden 305 päivän maitotuotos ja elinikäistuotos sekä runko-ominaisuudet olivat takakorkeus, rungon syvyys, rinnan leveys, lypsytyyppisyys, selkälinja, lantion leveys ja lantion kulma. Satunnaistekijöiden varianssikomponenttien sekä periytymisasteiden arvioimiseen käytettiin DMU-ohjelmaa Restricted Maximum Likelihood (REML) –menetelmää käyttäen. Periytymisasteen arvioksi saatiin ensikkotuotokselle 0,28 ja elinikäistuotokselle 0,08. Hedelmällisyysominaisuuksien periytymisasteiden arviot olivat hyvin alhaisia (0,02 – 0,03) sekä hiehoilla että ensikoilla. Runko-ominaisuuksien periytymisaseet vaihtelivat välillä 0,10 – 0,43. Korkeimmat periytymisasteen arviot olivat takakorkeudella (0,43) ja lantion kulmalla (0,27). Suurimmat positiiviset korrelaatiot saatiin lypsytyyppisyyden ja ensikkotuotoksen (0,51) sekä lypsytyyppisyyden ja elinikäistuotoksen (0,45) välille, ja suurin negatiivinen korrelaatio saatiin selkälinjan ja ensikkotuotoksen (-0,33) välille. Ensikoiden runko-ominaisuuksista rinnan leveydellä ja lantion kulmalla oli kohtalainen geneettinen yhteys lepokauteen. Rungon syvyys, lantion leveys ja kulma korreloivat merkitsevästi hiehojen tiinehtymisen kanssa. Hiehojen hedelmällisyysominaisuuksien ja elinikäistuotoksen väliset geneettiset korrelaatiot olivat kohtalaisia ja positiivisia. Tässä tutkimuksessa lepokauden ja tuotosominaisuuksien välillä ei havaittu perinnöllistä yhteyttä. Hedelmällisyys ja elinikäistuotos ovat vain heikosti periytyviä ominaisuuksia. Runkorakenteen ja ensikkotuotoksen parantaminen jalostuksella on kohtalaisen nopeaa, koska ne periytyvät keskinkertaisesti. Tämän tutkimuksen perusteella joidenkin runko-ominaisuuksien valinta edistää ensikkotuotosta heikentäen samalla hedelmällisyyttä ja elinikäistuotosta. Hiehojen huono hedelmällisyys oli yhteydessä korkean elinikäistuotoksen kanssa, kuitenkaan ei ole mielekästä painottaa valinnassa huonoa hiehojen hedelmällisyyttä.Genetic and phenotypic parameters and relationships for fertility traits, body type traits and production were estimated. The data analyzed included 21,450 Ayrshires. Animals were reared in 2,647 herds, born from 1994 to 2005 and were progeny of 1652 sires. Analyzed fertility traits were days from first service to last insemination and number of inseminations to conception for heifers, and days from calving to first insemination for first parity cows. Production traits were first lactation milk and lifetime milk and body type traits were stature, body depth, chest width, angularity, top line, rump width and rump angle. Variance components and the heritability estimates were calculated by restricted maximum likelihood (REML) method using the DMU software. The heritability estimates of first lactation milk yield and lifetime milk yield were 0.28 and 0.08, re-spectively. The heritabilities for fertility traits in virgin heifers and first lactation cows were low (0.02 – 0.03). Heritability estimates for the type traits varied from 0.10 to 0.43. The largest heritability was found for stature (0.43) and rump width (0.27). The highest positive genetic correlations were angularity with first lactation milk (0.41) and lifetime milk (0.45), and the highest negative genetic correlation was between top line and first lactation milk (-0.33). Chest width and rump angle had a positive genetic correlation to days from calving to first insemination. The significant genetic correlations were heifer fertility with body depth, rump width and rump angle. Estimated correlations between heifer fertility traits and lifetime milk yield were positive and moderate. First parity cow fertility was not related to production traits. Fertility traits and lifetime milk have a low heritability. Progress can be made relatively fast in body traits and first lactation milk by breeding, because of the moderate heritabilities. Selection for some body type traits may cause improvement in production but deterioration in fertility. Declined heifer fertility is associated with high lifetime production. However is not reasonable to put emphasis on poor heifer fertility in selection

Adolescent Social Capital – An Intergenerational Resource?

Introduction: Social capital is a valuable asset that spawns multiple benefits, but littleis known about its origins. This study narrows the gap by exploring the extent to whichadolescents’ social capital is shaped by their parents’ social capital, the socioeconomicstatus (SES) of their families, or that of their neighbourhood. The study also exploreswhich dimensions of adolescent social capital are most sensitive to intergenerational orsocioeconomic influence.Methods: The study uses cross-sectional survey data gathered from adolescents aged12–13 years and their parents (n = 167) in Southwest Finland. For the analysis,adolescents’ social capital was disaggregated into four dimensions: social networks,social trust, tendency to receive help, and tendency to provide help. For each dimension,the associations with the hypothesised predictors were analysed separately usingstructural equation modelling.Results: The results suggest that parents’ social capital is the most influential predictorto each dimension of adolescents’ social capital establishing stronger associations ascompared to the other two predictors. However, it is not the parents’ actual socialcapital as they report themselves, but their offspring’s perception of their socialbehaviour. Family’s SES relates to young people’s reciprocal tendency and level of trustbut only indirectly through parents’ social capital. Conversely, a disadvantagedsocioeconomic neighbourhood is directly negatively associated with adolescents’ levelof trust and frequency of receiving help.Conclusions: This study suggests that social capital is distinctly, although notexclusively, an intergenerational resource. Parents are critical role models for adolescentchildren</p

Major or minor placenta previa : Does it make a difference?

Introduction: Placenta previa is a severe pregnancy complication with considerable maternal and neonatal morbidity. Placenta previa can be defined as major or minor by location. Major placenta previa is associated with higher complication rates. Management of women with minor placenta previa has not been well defined. The primary goal of the study was to evaluate the accuracy of our existing screening protocol for placenta previa. Secondly, we wanted to compare pregnancy and delivery outcomes by the type of placenta previa. Methods: The study was conducted at the Helsinki University Hospital between June 2010 and September 2014. The study population consisted of all women with the antenatal ultrasound diagnosis of placenta previa during delivery. Data were retrospectively collected and analysed. Results: Altogether 176 women had placenta previa at delivery (major 129, minor 47). Placenta previa remained undiagnosed at second trimester screening ultrasound in 32 women (18.2%). Twenty (62.5%) of these cases had minor placenta previa and 12 (37.5%) had major placenta previa. Five (15.6%) of the undiagnosed cases developed life-threatening hemorrhage (>= 2500 ml) during the delivery and two had abnormally invasive placenta followed by hysterectomy. Women with major placenta previa had significantly more blood loss and delivered earlier than women with minor placenta previa. The groups were otherwise similar, including the rate of abnormally invasive placenta. Discussion: The existing protocol for placenta previa missed almost one fifth of cases. Both major and minor placenta previa are risk factors for abnormally invasive placenta and should be treated as severe conditions.Peer reviewe

Istukan kiinnittymishäiriö - äidin henkeä uhkaava raskauskomplikaatio

English summar

Statistical Permutation Test Reveals Progressive and Region-Specific Iron Accumulation in the Thalami of Children with Aspartylglucosaminuria

Aspartylglucosaminuria (AGU) is a rare lysosomal storage disorder causing developmental delay, intellectual disability, and eventual death. A distinct feature in AGU is iron accumulation within the thalamus. Our aim is to demonstrate that susceptibility-weighted images (SWI) could be used as an MRI biomarker to evaluate the response within the AGU population to newly evolving treatments. SWI from 16 patients with AGU and 16 age-matched controls were used in the analysis. Thalamic volume with an iron accumulation was identified using a permutation test. Group differences were investigated for both the complete thalamus and the iron accumulation regions. Group-wise age correlation within these volumes were assessed with analysis of variance and multivariate regression. We found a statistically significant and large difference (p-value = 0.01, Cohen’s D = 0.97) for the whole thalamus comparison and an even greater difference in the iron accumulation regions (p-value < 0.01, Cohen’s D = 3.52). Furthermore, we found strong evidence for iron accumulation as a linear function of age with R2 = 0.65 only for AGU. The statistical analysis of SWI provides tools for assessing the degree of iron accumulation. This method could be used to study the response to treatments, in that a successful treatment would be expected to result in a decline in iron accumulation

Is there an association between postpartum hemorrhage, interventional radiology procedures, and psychological sequelae?

Background: Postpartum hemorrhage (PPH) may cause post-traumatic psychological sequelae. Interventional radiology procedures (IRP) have been established in the management of PPH when conventional management fails. IRP is also used prophylactically in women who are at high risk for PPH in pregnancies with abnormally invasive placentation. We sought to determine if there is an association between PPH, IRP, and psychological sequelae. Objectives: Seventy-three women who underwent IRP due to PPH or were at high risk for PPH. Method: A structured questionnaire was sent to all women. Results: Overall 49 women returned the questionnaire. Two-thirds of the women developed psychological sequelae and one-third reported a lack of professional support. Nine women had symptoms of post-traumatic stress disorder. Psychological sequelae were not associated with a volume of bleeding, whether or not hysterectomy was performed, or whether the IRP was performed as an emergency procedure or prophylactically. However, women who had elective IRP and no hysterectomy performed had significantly less fear of death compared to the rest of the study population. Conclusions: We observed a high rate of psychological sequelae associated with IRP. Lack of proper professional support may have contributed to the development of post-traumatic psychological sequelae suggesting a need for debriefing in such women.Peer reviewe

Pregnancy-associated stroke -a systematic review of subsequent pregnancies and maternal health

BackgroundPregnancy-associated stroke is a rare but life-threatening event, with an estimated incidence of 30/100000 deliveries. Data on the risk of stroke recurrence and the risk of other adverse pregnancy outcomes are essential for adequate counselling and surveillance in subsequent pregnancies. The aim of this systematic review is to describe the implications of a pregnancy-associated stroke for the future health of these women.MethodsWe searched Ovid Medline, PubMed, Cochrane Library and CINAHL for articles published in 1980-2018. Articles including women with pregnancy-associated stroke and information on at least one of the following outcomes were included: 1) recurrence of stroke during subsequent pregnancy, 2) number and course of subsequent pregnancies and their outcomes and 3) subsequent cardiovascular health.ResultsTwelve articles were included in the review, with six providing information on subsequent pregnancies, four on subsequent maternal health and two on both. The included articles varied greatly in terms of study design, length of follow up and reported outcomes. We found 252 women with pregnancy-associated stroke for whom the outcomes of interest were reported: 135 women with information on subsequent pregnancies and 123 women with information on future health. In total, 55 pregnancies after stroke were found. In the majority of studies, the incidence of pregnancy complications was comparable to that of the general population. The risk of stroke recurrence during pregnancy was 2%. Data on subsequent health of these women were limited, and the quality of the data varied between the studies.ConclusionsData on subsequent pregnancies and health of women with a history of pregnancy-associated stroke are limited. Further research on this topic is essential for adequate counselling and secondary prevention.Peer reviewe