Ragnheiður Ingibjörg Bjarnadóttir

Introduction: Interpreting the histopathology report after stillbirth and applying it to care in a subsequent pregnancy can be challenging. Material and Methods: A retrospective cohort study of singleton stillbirths in Iceland 1996–2021 ( n = 338). Clinical information and description of placenta and umbilical cord were reviewed, and microscopic slides re‐evaluated according to the Amsterdam Consensus. Clinical and histopathological findings, including major patterns of placental injury and umbilical cord at risk, were correlated and compared between gestational age groups: n = 102), ≥28 but n = 114), and ≥37 weeks ( n = 122). Results: Placental slides were reviewed for 96.4% (326/338) of singleton stillbirths and classified into major patterns of placental injury. Maternal vascular malperfusion (MVM) was diagnosed in 19.0% of placentas (62/326), fetal vascular malperfusion (FVM) in 31.6% (103/326), acute chorioamnionitis (ACA) in 32.2% (105/326), chronic villitis of unknown etiology (VUE) in 15.9% (52/326), and none of the major patterns in 27.9% (91/326). More than one pattern of placental injury was found in 7.7% of placentas (25/326), most often at term. A similar proportion of MVM was found irrespective of gestational age; FVM was more common after 28 weeks, ACA before 28 weeks, but VUE most frequent at term. A higher proportion of MVM was found in stillbirths with small for gestational age (SGA) infants than non‐SGA (23.0 vs. 6.1%), as well as in stillbirths with maternal hypertensive disorder of pregnancy than in stillbirths with a normotensive mother (23.9 vs. 11.8%). The latter association was not seen with high‐grade FVM nor VUE. The umbilical cord was at risk in 53.8% (175/326) of singleton stillbirths, increasing with gestational age to 71.7% (86/120) at term. Hypercoiled, excessive long, and wrapped cords were most common. Term stillbirths with cord at risk often also had placental MVM or VUE. Conclusions: Understanding major patterns of placental injury and their correlation with clinical phenotypes can help counseling after stillbirth. Stillbirths with placental MVM often had clinical signs suggesting a high‐risk pregnancy. However, term stillbirths with placental VUE or FVM and umbilical cord at risk were commonly without recognized risk factors.

Introduction: This study describes the stillbirth rate (SBR) in Iceland 1996–2021 and the causes of stillbirth according to the Stockholm classification of stillbirth, comparing time periods and gestational age (GA) groups. Material and Methods: Clinical information was obtained from medical records of mothers who had stillbirths and their infants ( n = 395). Infants were divided into groups according to GA at diagnosis of stillbirth: early preterm: ≥22 but n = 140), late preterm: ≥28 but n = 130), and term: ≥37 weeks ( n = 125). Autopsy records and gross descriptions of the placenta were reviewed, and microscopic slides were reevaluated, and findings classified according to the Amsterdam Consensus. Primary and associated causes of death were assigned according to the Stockholm classification of stillbirth. The SBR, maternal and fetoplacental characteristics, and causes of death were compared between two 13‐year periods (1996–2008 and 2009–2021) and between GA groups. Results: The SBR decreased from 4.10 to 2.88/1000 births ( p = 0.009) between the two periods, but this decrease was limited to stillbirths diagnosed before term. Fewer stillbirths in the latter period were attributed to causes such as infection and placental abruption, and unexplained stillbirths reduced (0.59 vs. 0.16/1000, p < 0.05). The most common primary causes of stillbirth were reduced circulation in the umbilical cord (25.6%) and placental insufficiency (25.2%); both increased in incidence with more advanced gestation. Despite no difference in small‐for‐gestational‐age infants, a larger percentage of stillbirths had low placental weight (21.3% vs. 30.3%, p = 0.002) and high fetoplacental ratio for GA (15.7% vs. 24.2%, p = 0.005) in the latter period, when a larger proportion of stillbirths were attributed to placental insufficiency (17.0% vs. 37.0%, p = 0.0002). Conclusions: The SBR decreased in the latter period due to a reduction in preterm stillbirth, whereas the SBR at term was unchanged. Reduced circulation of the umbilical cord and placental insufficiency were the commonest causes, and both increased with GA. Stillbirth due to infection and placental abruption, as well as unexplained stillbirths, decreased during the study period, whereas deaths attributed to placental insufficiency became more common, reflecting a lack of reduction of stillbirth at term in the latter period.

Introduction: Use of labor induction has increased rapidly in most middle‐ and high‐income countries over the past decade. The reasons for the stark rise in labor induction are largely unknown. We aimed to assess the extent to which the rising rate of labor induction is explained by changes in rates of underlying indications over time.Material and methods: The study was based on nationwide data from the Icelandic Medical Birth Register on 85 620 singleton births from 1997 to 2018. The rate of labor induction and indications for induction was calculated for all singleton births in 1997–2018. Change over time was expressed as relative risk (RR), using Poisson regression with 95% confidence intervals (CI) adjusted for maternal characteristics and indications for labor induction.Results: The crude rate of labor induction rose from 12.5% in 1997–2001 to 23.9% in 2014–2018 (crude RR = 1.91, 95% CI 1.81–2.01). While adjusting for maternal characteristics had little impact, adjusting additionally for labor induction indications lowered the RR to 1.43 (95% CI 1.35–1.51). Induction was increasingly indicated from 1997–2001 to 2014–2018 by gestational diabetes (2.4%–16.5%), hypertensive disorders (7.0%–11.1%), prolonged pregnancy (16.2%–23.7%), concerns for maternal wellbeing (3.2%–6.9%) and maternal age (0.5%–1.2%). No indication was registered for 9.2% of inductions in 2014–2018 compared with 16.3% in 1997–2001.Conclusions: Our results show that the increase in labor induction over the study period is largely explained by an increase in various underlying conditions indicating labor induction. However, indications for 9.2% of labor inductions remain unexplained and warrant further investigation.

Introduction: Obstetric interventions appear to increase with advancing maternal age, but limited supporting evidence exists, particularly for young women and specifically for prelabor and intrapartum cesarean birth. The aim of this study was to explore the association between obstetric interventions and maternal age in a low‐risk population.Methods: The study was restricted to all low‐risk, nulliparous women with singleton, vertex, term births who gave birth in Iceland from 1997 to 2015, identified in the Icelandic Medical Birth Registry. Logistic regression models were used to calculate adjusted odds ratios (aORs) and 95% CIs for the risks of labor induction, instrumental birth, and cesarean birth (prelabor and intrapartum), according to maternal age group. All models were adjusted for gestational age, year of birth, and demographic factors, and the models for intrapartum cesarean birth were also adjusted for dystocia and fetal distress.Results: For women aged more than 40 years, the aOR for induction of labor was 4.69 (95% CI, 3.2‐6.8) compared with women aged between 25 and 29 years. In women aged more than 40 years, the increased risks for prelabor cesarean birth and intrapartum cesarean birth were 7.4 (95% CI, 3.0‐18.0) and 3.6 (95% CI, 2.1‐6.0), respectively. The risk of instrumental birth was slightly increased for women aged between 35 and 39 years (aOR, 1.6; 95% CI, 1.3‐2.0), compared with women aged between 25 and 29 years, but not for women aged at least 40 years (aOR, 1.1; 95% CI, 0.7‐1.9). For women aged less than 20 years, the risk of induction of labor (aOR, 0.8; 95% CI, 0.7‐0.9) and instrumental births (aOR, 0.6; 95% CI, 0.5‐0.7) was reduced compared with women aged between 25 and 29 years.Discussion: The risk of interventions generally increased with increasing maternal age, but the risk of instrumental births was not increased for women aged over 40 years. Also, young women were at a decreased risk of induction of labor and instrumental births.

Introduction Severe obstetric complications increase with the number of previous cesarean deliveries. In the Nordic countries most women have two children. We present the risk of severe obstetric complications at the delivery following a first elective or emergency cesarean and the risk by intended mode of second delivery. Material and methods A two‐year population‐based data collection of severe maternal complications in women with two deliveries in the Nordic countries (n = 213 518). Denominators were retrieved from the national medical birth registers. Results Of 35 450 first cesarean deliveries (17%), 75% were emergency and 25% elective. Severe complications at second delivery were more frequent in women with a first cesarean than with a first vaginal delivery, and rates of abnormally invasive placenta, uterine rupture and severe postpartum hemorrhage were higher after a first elective than after a first emergency cesarean delivery [relative risk (RR) 4.1, 95% confidence intervals (CI) 2.0–8.1; RR 1.8, 95% CI 1.3–2.5; RR 2.3, 95% CI 1.5–3.5, respectively]. A first cesarean was associated with up to 97% of severe complications in the second pregnancy. Induction of labor was associated with an increased risk of uterine rupture and severe hemorrhage. Conclusion Elective repeat cesarean can prevent complete uterine rupture at the second delivery, whereas the risk of severe obstetric hemorrhage, abnormally invasive placenta and peripartum hysterectomy is unchanged by the intended mode of second delivery in women with a first cesarean. Women with a first elective vs. an emergency cesarean have an increased risk of severe complications in the second pregnancy.

Introduction: The cesarean rates are low but increasing in most Nordic countries. Using the Robson classification, we analyzed which obstetric groups have contributed to the changes in the cesarean rates.Material and methods: Retrospective population‐based registry study including all deliveries (3 398 586) between 2000 and 2011 in Denmark, Finland, Iceland, Norway and Sweden. The Robson group distribution, cesarean rate and contribution of each Robson group were analyzed nationally for four 3‐year time periods. For each country, we analyzed which groups contributed to the change in the total cesarean rate.Results: Between the first and the last time period studied, the total cesarean rates increased in Denmark (16.4 to 20.7%), Norway (14.4 to 16.5%) and Sweden (15.5 to 17.1%), but towards the end of our study, the cesarean rates stabilized or even decreased. The increase was explained mainly by increases in the absolute contribution from R5 (women with previous cesarean) and R2a (induced labor on nulliparous). In Finland, the cesarean rate decreased slightly (16.5 to 16.2%) mainly due to decrease among R5 and R6–R7 (breech presentation, nulliparous/multiparous). In Iceland, the cesarean rate decreased in all parturient groups (17.6 to 15.3%), most essentially among nulliparous women despite the increased induction rates.Conclusions: The increased total cesarean rates in the Nordic countries are explained by increased cesarean rates among nulliparous women, and by an increased percentage of women with previous cesarean. Meanwhile, induction rates on nulliparous increased significantly, but the impact on the total cesarean rate was unclear. The Robson classification facilitates benchmarking and targeting efforts for lowering the cesarean rates.

Introduction: Rates of severe perineal tears and episiotomies are indicators of obstetrical quality of care, but their use for international comparisons is complicated by difficulties with accurate ascertainment of tears and uncertainties regarding the optimal rate of episiotomies. We compared rates of severe perineal tears and episiotomies in European countries and analysed the association between these two indicators.Material and methods: We used aggregate data from national routine statistics available in the Euro‐Peristat project. We compared rates of severe (third‐ and fourth‐degree) tears and episiotomies in 2010 by mode of vaginal delivery (n = 20 countries), and investigated time trends between 2004 and 2010 (n = 9 countries). Statistical associations were assessed with Spearman's ranked correlations (rho).Results: In 2010 in all vaginal deliveries, rates of severe tears ranged from 0.1% in Romania to 4.9% in Iceland, and rates of episiotomies from 3.7% in Denmark to 75.0% in Cyprus. A negative correlation between the rates of episiotomies and severe tears was observed in all deliveries (rho = −0.66; p = 0.001), instrumental deliveries (rho = −0.67; p = 0.002) and non‐instrumental deliveries (rho = −0.72; p < 0.001). However there was no relation between time trends of these two indicators (rho = 0.43; p = 0.28).Conclusions: The large variations in severe tears and episiotomies and the negative association between these indicators in 2010 show the importance of improving the assessment and reporting of tears in each country, and evaluating the impact of low episiotomy rates on the perineum.

There is a scarcity of data on the association of sexual violence and women's subsequent obstetric outcomes. Our aim was to investigate whether women exposed to sexual violence as teenagers (12–19 years of age) or adults present with different obstetric outcomes than women with no record of such violence. We linked detailed prospectively collected information on women attending a Rape Trauma Service (RTS) to the Icelandic Medical Birth Registry (IBR). Women who attended the RTS in 1993–2010 and delivered (on average 5.8 years later) at least one singleton infant in Iceland through 2012 formed our exposed cohort (n = 1068). For each exposed woman's delivery, nine deliveries by women with no RTS attendance were randomly selected from the IBR (n = 9126) matched on age, parity, and year and season of delivery. Information on smoking and Body mass index (BMI) was available for a sub-sample (n = 792 exposed and n = 1416 non-exposed women). Poisson regression models were used to estimate Relative Risks (RR) with 95% confidence intervals (CI). Compared with non-exposed women, exposed women presented with increased risks of maternal distress during labor and delivery (RR 1.68, 95% CI 1.01–2.79), prolonged first stage of labor (RR 1.40, 95% CI 1.03–1.88), antepartum bleeding (RR 1.95, 95% CI 1.22–3.07) and emergency instrumental delivery (RR 1.16, 95% CI 1.00–1.34). Slightly higher risks were seen for women assaulted as teenagers. Overall, we did not observe differences between the groups regarding the risk of elective cesarean section (RR 0.86, 95% CI 0.61–1.21), except for a reduced risk among those assaulted as teenagers (RR 0.56, 95% CI 0.34–0.93). Adjusting for maternal smoking and BMI in a sub-sample did not substantially affect point estimates. Our prospective data suggest that women with a history of sexual assault, particularly as teenagers, are at increased risks of some adverse obstetric outcomes.