Laskimotukos raskauden aikana ja tukostaipumuksen merkitys raskauskomplikaatioissa

Venous thromboembolism (VTE) is the greatest single cause of maternal mortality in pregnant women in developed countries. Pregnancy is a hypercoagulable state and brings about an enhanced risk of deep venous thrombosis (DVT) in otherwise healthy women. Traditionally, unfractionated heparin (UFH) has been used for treatment of DVT during pregnancy. We showed in our observational study that low molecular weight heparin (LMWH) is as effective and safe as UFH in the treatment of DVT during pregnancy. Although DVT during pregnancy is often massive, increasing the risk of developing long-term consequences, namely post-thrombotic syndrome (PTS), only 11% of all patients had confirmed PTS 3 4 years after DVT. In our studies the prevalence of PTS was not dependent on treatment (UFH vs LMWH). Low molecular weight heparin is more easily administered, few laboratory controls are required and the hospital stay is shorter, factors that lower the costs of treatment. Cervical insufficiency is defined as repeated very preterm delivery during the second or early third trimester. Infection is a well-known risk factor of preterm delivery. We found overpresentation of thrombophilic mutations (FV Leiden, prothrombin G20210A)among 42 patients with cervical insufficiency compared with controls (OR 6.7, CI 2.7 18.4). Thus, thrombophilia might be a risk factor of cervical insufficiency possibly explained by interaction of coagulation and inflammation processes. The presence of antiphospholipid (aPL) antibodies increases the risk for recurrent miscarriage (RM). Annexins are proteins which all bind to anionic phospholipids (PLs) preventing clotting on vascular phospholipid surfaces. Plasma concentrations of circulating annexin IV and V were investigated in 77 pregnancies at the beginning of pregnancy among women with a history of RM, and in connection to their aPL antibody status. Control group consisted unselected pregnant patients (n=25) without history of adverse pregnancy outcome. Plasma levels of annexin V were significantly higher at the beginning (≤5th week) of pregnancy in women with aPL antibodies compared with those without aPL antibodies (P=0.03). Levels of circulating annexin V were also higher at the 6th (P= 0.01) and 8th week of pregnancy in subjects with aPL antibodies (P=0.01). Results support the hypothesis that aPL could displace annexin from anionic phospholipid surfaces of syncytiotrophoblasts (STBs) and may exert procoagulant activities on the surfaces of STBs Recurrent miscarriage (RM) has been suggested to be caused by mutations in genes coding for various coagulation factors resulting in thrombophilia. In the last study of my thesis were investigated the prevalence of thrombomodulin (TM) and endothelial protein C receptor polymorphism EPCR among 40 couples and six women suffering RM. This study showed that mutations in the TM or EPCR genes are not a major cause of RM in Finnish patients.Laskimotukos raskauden aikana ja tukostaipumuksen merkitys raskauskomplikaatioissa Tromboembolinen komplikaatio on yleisin äidin henkeä uhkaava raskauteen liittyvä komplikaatio kehittyneissä maissa. Raskaus itsessään aiheuttaa terveellekin naiselle tukostaipumukseen verrattavan tilan johon liittyy kohonnut riski laskimotukokselle. Perinteisesti raskaudenaikaisen laskimotukoksen hoidossa on käytetty fraktioimatonta hepariinia (UFH). Osoitimme tutkimuksissamme että pienmolekylaarinen hepariini (LMWH) on yhtä tehokas ja turvallinen kuin fraktioimaton hepariini myös raskaudenaikaisen laskimotukoksen hoidossa. Koska raskaudenaikainen laskimotukos on usein laaja, on myöhäisoireiden eli post-tromboottisen syndrooman riski suurentunut. Tutkimuksessamme todettiin 3-4 vuotta sairastetun laskimotukoksen jälkeen vain 11%:lla potilaista vaikea post-tromboottinen syndrooma. Tutkimuksessamme käytetty hoito (UFH vs LMWH) ei vaikuttanut post-tromboottisen syndrooman ilmentymiseen. Pienmolekylaarinen hepariini on yksinkertaisempi annostella, ja sen vaikutus elimistössä on paremmin ennakoitavissa joten hoidon aikana tarvitaan vähemmän laboratorioseurantaa. Nämä seikat lyhentävät sairaalahoidon tarvetta ja vähentävät hoidon kustannuksia. Kohdunkaulan heikkous määritellään toistuvaksi ennenaikaiseksi synnytykseksi toisella tai varhaisella kolmannella raskauskolmanneksella. Infektio on tunnettu ennenaikaisuuden riskitekijä. Infektio tiedetään myös lisäävän veren hyytymisaktiviteettia. Tutkimuksessamme löydettiin merkitsevästi enemmän tukostaipumuksen aiheuttavia geenivirheitä (FV Leiden, protrombiini G20210A) potilailta, joilla oli varmistettu kohdunkaulan heikkous-diagnoosi kuin terveiltä verrokeilta (OR 6.7, CI 2.7-18.4). Tukostaipumus näyttäisi olevan riskitekijä toistuvalle ennenaikaiselle synnytykselle. Fosfolipidivasta-aineet (aPL) lisäävät riskiä toistuvaan keskenmenoon (kolme perättäistä). Anneksiiniproteiinit (antikoagulaatioproteiinit) sitoutuvat solukalvojen negatiivisesti varautuneisiin fosfolipidirakenteisiin ehkäisten fosfolipidivasta-aine välitteisen hyytymisjärjestelmän aktivoitumisen solukalvoilla. Tutkimuksessamme todettiin että potilailla jotka kärsivät toistuvista keskenmenoista ja oli todettu fosfolipidivasta-aineita, löydettiin merkitsevästi enemmän liukoista anneksiini V proteiinia verenkierrossa heti raskauden varmistuttua (P=0.03), 7. raskausviikolla (P=0.01) ja 9. raskausviikolla (P=0.01) kuin potilailla joilla fosfolipidivasta-aineita ei oltu todettu tai terveillä raskaana olevilla verrokeilla. Tulos vahvistaa teoriaa että fosfolipivasta-aineilla on kyky syrjäyttää anneksiinia syncytiotrofoblastien solukalvoilta lisäten hyytymisaktiivisuutta syncytiotrofoblastien pintarakenteissa. Tukostaipumusta aiheuttavia geenivirheitä on ehdotettu, fosfolipidivasta-aineiden lisäksi, toistuvan keskenmenon riskitekijäksi. Viimeisessä väitöskirjan osatyössä selvitettiin Trombomoduliinin (TM) ja endoteliaalisen proteiini C-reseptorin (EPCR) polymorfismin esiintymistä pariskunnilla (40 paria ja 6 naista) jotka kärsivät toistuvista keskenmenoista. Koe-eläinmalleissa kyseiset näiden TM ja EPCR geenipoikkeavuudet ovat lisänneet keskenmenoalttiutta. Tutkimuksemme perusteella ihmisen TM ja EPCR geenimutaatiot eivät ole merkittävä syy toistuvalle keskenmenolle

Effect of hospital size and on-call arrangements on intrapartum and early neonatal mortality among low-risk newborns in Finland

Objective: To evaluate the influence of delivery unit size and on-call staffing in the performance of low-risk deliveries in Finland. Study design: A population-based study of hospital size and level based on Medical Birth Register data. Population was all hospital births in Finland in 2005-2009. Inclusion criteria were singleton births (birth weight 2500 g or more) without major congenital anomalies or birth defects. Additionally, only intrapartum stillbirths were included. Birthweights and maternal background characteristics were adjusted for by logistic regression. Main outcome measures were intrapartum or early neonatal mortality, neonatal asphyxia and newborns' need for intensive care or transfer to other hospital and longer duration of care. On-call arrangements were asked from each of the hospitals. Results: Intrapartum mortality was higher in units where physicians were at home when on-call (OR 1.25; 95% CI 1.02-1.52). A tendency to a higher mortality was also recorded in non-university hospitals (OR 1.18; 95% CI 0.99-1.40). Early neonatal mortality was twofold in units with less than 1000 births annually (OR 2.11; 95% CI 0.97-4.56) and in units where physicians were at home when on-call (OR 1.85; 95% CI 0.91-3.76). These results did not reach statistical significance. No differences between the units were found regarding Apgar scores or umbilical cord pH. Conclusion: The differences in mortality rates between different level hospitals suggest that adverse outcomes during delivery should be studied in detail in relation to hospital characteristics, such as size or level, and more international studies determining obstetric patient safety indicators are required. (C) 2016 Elsevier Ireland Ltd. All rights reserved.Peer reviewe

The impact of increased number of low-risk deliveries on maternal and neonatal outcomes: A retrospective cohort study in Finland in 2011-2015

Objectives: Our aim was to demonstrate the influence of increased number of low-risk deliveries on obstetric and neonatal outcome. Study design: The study hospital was Katiloopisto Maternity Hospital in Helsinki. Simultaneously, we studied all three delivery units in the Helsinki region in the population-based analysis. The study population was singleton hospital deliveries occurring between 2011 and 2012, and 2014-2015. The study hospital included 11 237 and 15 637 births and the population-based group included 28 950 and 27 979 births. We compared outcome measures in different periods by calculating adjusted odds ratios (AOR). Main outcome measures were induced delivery, mode of delivery, third or fourth degree perinea, tear, Apgar score at five minutes 7 days, and perinatal death. Results: In the study hospital, induction rate increased from 22.4% to 24.8% (AOR 1.06, 95% CI; 1.00-1.12) while in the population-based analysis the rate decreased from 22.2% to 21.5% (AOR 0.96, 95% CI; 0.92-1.00). Percentage of neonatal transfers, low Apgar scores, and severe perineal tears increased both in study hospital and in population-based group. Changes in operative delivery rate and other adverse perinatal outcomes were statistically insignificant. Conclusions: Increasing the volume of a delivery unit does not compromise maternal or neonatal outcome. Specific characteristics of a delivery unit affect the volume outcome association. (C) 2018 Elsevier B.V. All rights reserved.Peer reviewe

Raskaus ja laskimotukos

English summaryPeer reviewe

Maternal childbirth experience and time of delivery : a retrospective 7-year cohort study of 105 847 parturients in Finland

Objectives To explore how the time of delivery influences childbirth experience. Design A retrospective cohort study. Setting Childbirth in the four Helsinki and Uusimaa Hospital District hospitals, Finland, from 2012 to 2018. Participants 105 847 childbirths with a singleton live fetus. Main outcome measures Childbirth experience measured by Visual Analogue Scale (VAS). Results The major difference in average childbirth experience measured by VAS was between primiparas (8.03; 95% CI 8.01 to 8.04) and multiparas (8.47; 95% CI 8.45 to 8.48). Risk ratio (RR) of the low VAS ( Conclusion The maternal childbirth experience depended on the time of delivery. Giving birth during the evening led to impaired childbirth experience in both primiparas and multiparas, compared with delivery at other times. The impact of labour induction on childbirth experience should be further examined. The reorganisation of delivery services and the reduction of birth preparations might affect annual VAS. VAS is a simple method of measuring the complex entity of childbirth experience, and our results indicate its ability to capture temporal variation.Peer reviewe

Maternal childbirth experience and pain relief methods: a retrospective 7-year cohort study of 85 488 parturients in Finland

Objectives The aim of this study was to analyse the relation between the used labour pain relief and childbirth experience measured by Visual Analogue Scale (VAS).Design A retrospective cohort study.Setting Childbirth in five Helsinki University Hospital delivery units from 2012 to 2018.Primary outcome measure Childbirth experience measured by VAS and classified in three groups (negative VAS=1textendash5, positive VAS=6textendash8 and highly positive=9textendash10).Results The use of epidural or non-epidural compared with non-medical pain relief methods decreased the likelihood to experience highly positive childbirth for primiparous (adjusted OR (aOR)EPIDURAL=0.64, 95.57 to 0.73; and aORNON-EPIDURAL=0.76, 95.66 to 0.87) and multiparous (aOREPIDURAL=0.90, 95.84 to 0.97 and aORNON-EPIDURAL=0.80, 95.74 to 0.86) parturients. The effects of epidural differed between primiparas and multiparas. In multiparas epidural was associated with decreased odds for experiencing negative childbirth compared with the non-medical group (aOR=0.70, 95.57 to 0.87), while the effect of epidural was considered insignificant in primiparas (aOR=1.28, 95.93 to 1.77).Conclusion While the use of medicaltextemdashepidural and non-epiduraltextemdashpain relief methods were not associated with odds for experiencing negative childbirth in primiparas, using epidural helps to avoid negative experience in multiparas. However, the odds for experiencing highly positive childbirth were decreased if the parturients used any medical pain relief for both primiparas and multiparas. Consequently, the effect of pain relief on the childbirth experience is strongly confounded by indication. Thus, the use of pain relief per se plays a limited role in the complex formation of the overall childbirth experience.No data are available. The data was granted to use in this study and is not allowed to reuse without other permission.Peer reviewe

Induction of labor in breech presentations at term : a retrospective observational study

Objective The aim of this study is to evaluate whether induction of breech delivery at term is feasible and safe for mother and child compared with spontaneous vaginal breech delivery. Study design A total of 268 singleton term breech deliveries with an attempted vaginal delivery were identified in a single-center retrospective observational study. Out of these, 73 cases had an induction of labor for various medical and obstetric reasons and were compared to 195 spontaneous singleton breech deliveries. The main outcome measure was the mode of delivery. Secondary outcomes included maternal and neonatal morbidity and mortality. Results The vaginal delivery rate in the induction group was 64.4 % compared with 80 % in the spontaneous delivery group. No statistical differences were observed between the two delivery groups regarding neonatal and maternal morbidity and mortality. Conclusions The vaginal delivery rate was significantly lower in induced than in spontaneous breech deliveries. The neonatal and maternal morbidity and mortality rates were similar implying that induction in breech delivery is an option and it is time for clinical reappraisal.Peer reviewe

Maternal childbirth experience and induction of labour in each mode of delivery: a retrospective seven-year cohort study of 95,051 parturients in Finland

Childbirth experience has been shown to depend on the mode of delivery. However, it is unclear how labour induction influences the childbirth experience in different modes of delivery. Thus, we assessed the childbirth experience among mothers with spontaneous and induced labours.Background Childbirth experience has been shown to depend on the mode of delivery. However, it is unclear how labour induction influences the childbirth experience in different modes of delivery. Thus, we assessed the childbirth experience among mothers with spontaneous and induced labours. Design A retrospective cohort study. Setting Childbirths in four delivery hospitals in Helsinki and Uusimaa District, Finland, in 2012-2018. Sample 95051 childbirths excluding elective caesarean sections. Methods Obstetric data combined to maternal childbirth experience measured by Visual Analogue Scale (VAS) was analysed with univariate linear modelling and group comparisons. The primiparas and multiparas were analysed separately throughout the study due to the different levels of VAS. Main outcome measures Maternal childbirth experience measured by VAS. Results The negative effect of labour induction on the childbirth experience was discovered in each mode of delivery. Operative deliveries were perceived more negatively when they were preceded by labour induction. The rate of poor childbirth experience (VASPeer reviewe

New Delivery Chair for Vaginal Delivery

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