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Background: An audit of all patients with rectal cancer in Sweden was launched in 1995. This is the first report from the Swedish Rectal Cancer Registry (SRCR). Methods: Between 1995 and 2003, 13 434 patients treated for adenocarcinoma of the rectum were registered with the SRCR; there were approximately 1500 new patients annually. Results: Approximately half had an anterior resection, a quarter an abdominoperineal resection and 15 per cent a Hartmann's procedure. The median 30-day postoperative mortality rate was 2.4 per cent and the overall postoperative morbidity rate was 35-0 per cent. The 5-year cancer-specific survival rate was 62.3 percent. The 5-year relative survival rate was 70.1 percent after anterior resection, 59.8 per cent after abdominoperineal resection and 39.8 per cent after a Hartmann's procedure. The crude 5-year local recurrence rate was 9.5 per cent overall, 6.1 per cent after preoperative radiotherapy and 11.4 per cent after surgery alone. For 3868 patients who had a locally curative procedure the local recurrence rate was 7.4 per cent overall, 5.9 per cent for those who had radiotherapy and 10.2 per cent for those who did not. The local recurrence rate was 2.9 per cent (28 of 968) for stage I disease, 7.9 per cent (112 of 1418) for stage 1I, 13.9 per cent (188 of 1357) for stage III and 8.5 per cent (45 of 532) for stage IV. Conclusion: These good population-based results are due, in part, to the nationwide prospective quality assurance registration. [ABSTRACT FROM AUTHOR]

Background: There is current interest in symptoms during pregnancy, but yet little is known about their prevalence and how often they are experienced across pregnancy. The reasons why some women experience more symptoms or experience them more often than others has received limited research attention.Objective: To document the prevalence and frequency of 27 pregnancy symptoms and to systematically investigate, cross-sectionally and prospectively, the effect of psychosocial factors on the prevalence and frequency of these symptoms, while controlling for biomedical factors.Methods: Four hundred and seventy-six nulliparous Scandinavian women who attended routine prenatal care in Uppsala county, Sweden, were studied six times during pregnancy (gestational weeks 10, 12, 20, 28, 32, and 36).Results: The prevalence of symptoms was high, but only a smaller portion of these symptoms were experienced frequently. Psychological stress particularly contributed to the prevalence and frequency of concurrent symptoms and predicted symptoms up to 16 weeks later, independent of medical risk, smoking, and weight gain.Conclusions: Prevalence rates may be inflated, because many symptoms were experienced only 'occasionally' during each of the 4-week periods we sampled. By examining how frequently symptoms were experienced, we gained an indication of which symptoms are more likely to be bothersome or intrude upon daily activities. Psychosocial variables accounted for individual differences in symptom reports after taking biomedical factors into account. Attention to psychosocial variables in future studies will aid in our understanding of the etiology of pregnancy symptoms. [ABSTRACT FROM AUTHOR]

Aim: This study investigates how often bowel continuity was restored after anastomotic leakage in anterior resection for rectal cancer and assesses the clinical factors associated with permanent stoma., Method: The Swedish Colorectal Cancer Registry was used to identify cases of anastomotic leakage registered in southern Sweden between January 2001 and December 2011. Patient characteristics, surgical details and clinical information about the anastomotic leakages were retrieved from medical records., Results: Of the 1442 patients operated on with anterior resection in 11 hospitals, 144 (10%) were diagnosed with anastomotic leakage after anterior resection for rectal cancer. After a median follow-up of 87 months (range 21-165), the overall rate of permanent stoma among patients with anastomotic leakage was 65%. Age ≥ 70 years (P = 0.02) and re-laparotomy (P < 0.001) were independently related to permanent stoma. Compared with nondefunctioned patients with anastomotic leakage, defunctioned patients with anastomotic leakage at the index procedure less often required re-laparotomy at some point during the entire clinical course (P < 0.001), but nondefunctioned and defunctioned patients with anastomotic leakage both had permanent stoma to the same extent (67% and 62%, respectively)., Conclusion: Anastomotic leakage is highly associated with permanent stoma after anterior resection, especially in patients aged ≥ 70 years. In this cohort of patients with anastomotic leakage, 65% had permanent stoma at long-term follow-up. A defunctioning stoma ameliorates the clinical course but does not affect the end result of bowel continuity in established anastomotic leakage after anterior resection., (Colorectal Disease © 2018 The Association of Coloproctology of Great Britain and Ireland.)

Aim: Anastomotic leakage (AL) is common after anterior resection (AR). Long term clinical outcomes of AL including late presenting leakage (LL) are not well studied. This study was undertaken to assess clinical features of LL with respect to incidence, association with predisposing factors and need for re-intervention., Methods: The Swedish Colorectal Cancer Registry (SCRCR) was explored for AL cases after AR for rectal cancer in patients operated in the south of Sweden from 1 January 2001 to 31 December 2011. Demographic data, surgical technical details, number of postoperative days (POD) until diagnosis of AL, presenting symptoms, methods of diagnosis and treatment were retrieved from medical records. LL was defined according to different cut-offs as leakages occurring after hospital discharge (LLAHD), after 30 POD (LL ≥ POD 30) and after 90 POD (LL ≥ POD 90)., Results: In total, 1442 patients were operated on with AR of whom 144 cases of AL (10%) were identified. Median time from operation to follow-up was 87 months (range 21-162). LLAHD, LL ≥ POD 30 and LL ≥ POD 90 were present in 51%, 24% and 9% respectively. All categories of LL were associated with a defunctioning stoma. Relaparotomy was significantly less often employed in LLAHD, but not in other categories of LL., Conclusion: LL constitutes a substantial portion of all AL after AR for rectal cancer. The large proportion of LLAHD calls for awareness in the outpatient setting., (Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.)

Background: During rectal cancer surgery the bowel may contain viable, exfoliated cancer cells, a potential source for local recurrence (LR). The amount and viability of these cells can be reduced using intraoperative rectal washout, a procedure that reduces the LR risk after anterior resection. The aim of this study was to analyse the impact of washout on oncological outcome when performed in Hartmann's procedure (HP) for rectal cancer., Methods: A national cohort study on data for patients registered from 1995 to 2007 in the Swedish Colorectal Cancer Registry was carried out. The final analysis included patients belonging to TNM stages I-III who had undergone R0 HP with a registered 5-year follow-up. Multivariate analysis was performed., Results: A total of 1188 patients were analysed (686 washout and 502 no washout). No differences were detected between the washout group and the no washout group concerning rates of LR [7% (49/686) vs. 10% (49/502); p = 0.13], distant metastasis (DM) [17% (119/686) vs. 18% (93/502); p = 0.65], and overall recurrence (OAR) [21% (145/686) vs. 24% (120/502); p = 0.29]. For both groups, the 5-year cancer-specific survival was below 50%. In multivariate analysis, washout neither decreased the risk of LR, DM, or OAR nor increased overall or the cancer-specific 5-year survival., Conclusions: The oncological outcome did not improve when washout was performed in HP for rectal cancer.

Aim: The main aims were to explore time trends in the management and outcome of patients with rectal cancer in a national cohort and to evaluate the possible impact of national auditing on overall outcomes. A secondary aim was to provide population-based data for appraisal of external validity in selected patient series., Method: Data from the Swedish ColoRectal Cancer Registry with virtually complete national coverage were utilized in this cohort study on 29 925 patients with rectal cancer diagnosed between 1995 and 2012. Of eligible patients, nine were excluded., Results: During the study period, overall, relative and disease-free survival increased. Postoperative mortality after 30 and 90 days decreased to 1.7% and 2.9%. The 5-year local recurrence rate dropped to 5.0%. Resection margins improved, as did peri-operative blood loss despite more multivisceral resections being performed. Fewer patients underwent palliative resection and the proportion of non-operated patients increased. The proportions of temporary and permanent stoma formation increased. Preoperative radiotherapy and chemoradiotherapy became more common as did multidisciplinary team conferences. Variability in rectal cancer management between healthcare regions diminished over time when new aspects of patient care were audited., Conclusion: There have been substantial changes over time in the management of patients with rectal cancer, reflected in improved outcome. Much indirect evidence indicates that auditing matters, but without a control group it is not possible to draw firm conclusions regarding the possible impact of a quality control registry on faster shifts in time trends, decreased variability and improvements. Registry data were made available for reference., (Colorectal Disease © 2015 The Association of Coloproctology of Great Britain and Ireland.)

Aim: A defunctioning loop ileostomy in low anterior resection reduces the incidence and morbidity of an anastomotic leakage, but complications related to the stoma may occur. We explored stoma-associated complications during the stoma period and after stoma reversal., Methods: A retrospective analysis of rectal cancer patients operated with low anterior resection and a defunctioning loop ileostomy at Helsingborg Hospital and Malmö University Hospital from January 2007 to June 2009 was undertaken., Results: Ninety-two patients were included, of whom 82 (89 %) underwent stoma reversal. The median stoma period was 6.2 ± 3.2 months. Sixty-six percent of the patients suffered from minor or major stoma-associated morbidity. The complication rate was significantly related to the stoma time (p < 0.01). Twenty-nine percent (27/92) had at least one episode of dehydration, leading to readmittance in half of the cases. Elderly patients were more prone to develop dehydration. Dehydration most commonly occurred early in the postoperative period (mean, 5.8 weeks). The mean hospital stay for stoma reversal was 6.5 ± 4.0 days. Forty percent (33/82) had some complication associated with the reversal., Conclusion: This study indicates high morbidity associated with defunctioning loop ileostomy. Our data suggest that the stoma time should be limited to reduce complications. Monitoring and early stoma reversal should be considered in elderly patients. Furthermore, stoma reversal is not uneventful, and more studies are needed to address how to minimize complications.

Aim: Despite advances in rectal cancer treatment, local recurrence (LR) remains a significant problem. To select high-risk patients for different treatment options aimed at reducing LR, it is essential to identify LR risk factors., Method: Local recurrence and survival rates of 4153 patients registered 1995-1997 in the Swedish Rectal Cancer Registry were analysed. LR risk factors were analysed by multivariate methods. For LR patients the registry was validated and additional data retrieved., Results: The 5-year overall and cancer-specific survival rates were 45% and 62% respectively. LR was registered in 326 (8%) patients. After R0-resections for tumours in TNM stages I-III, LR developed in 10% of tumours at 0-5 cm, 8% at 6-10 cm and 6% at 11-15 cm above the anal verge. Preoperative radiotherapy (RT) reduced the LR rate irrespective of height [0-5 cm: OR 0.50 (0.30-0.83), 6-10 cm: OR 0.42 (0.25-0.71), and 11-15 cm: OR 0.29 (0.13-0.64)]. Patients without preoperative RT had significantly higher LR risk after rectal perforation [OR 2.50 (1.48-4.24)], and almost significantly decreased LR risk when rectal washout was performed [OR 0.65 (0.43-1.00)]. Preoperative RT prolonged time to LR but did not significantly influence the survival among LR patients. LR was an isolated tumour manifestation in 103 (39%) patients with validated LR., Conclusion: Preoperative RT should be considered for rectal cancer also in the upper third of the rectum. Intraoperative perforation should be avoided, and rectal washout is indicated as valuable. Follow-up for the detection of isolated LR is important. Extended follow up should be considered for patients treated with RT., (© 2010 The Authors. Colorectal Disease © 2010 The Association of Coloproctology of Great Britain and Ireland.)

Background: Traditionally, risk identification in early pregnancy in Swedish antenatal care [ANC] is performed by the midwife at booking, and confirmed by the doctor at a routine visit in early pregnancy, but this extra visit has been questioned. This study compared the risk assessment by the two professions., Methods: In a cluster randomised trial, a planning conference, where midwives reported new mothers to a doctor, replaced the routine consultation with the doctor. Ten ANC-clinics with the new program (942 mothers) were compared to 10 clinics with standard care (758 mothers). Risk factors were registered independently by midwives and doctors. Degree of agreement in risk identification between midwives and doctors was estimated by the kappa coefficient., Results: The degree of agreement in risk registration was good for previous pregnancy complications (kappa = 0.62; CI: 0.55-0.68), and recommendations for the doctor's consultation (kappa = 0.67; CI: 0.62-0.72); fair for social problems (kappa = 0.29; CI: 0.03-0.55), and poor for registration of symptoms and problems in index pregnancy (kappa = 0.09; CI: 0.03-0.21) and psychosocial aspects, such as anxiety (kappa = 0.09; CI: 0.03-0.21). Significantly more risk factors were registered in the study group., Conclusions: Replacing the routine consultation with the doctor early in pregnancy with a planning conference had no negative impact on risk identification. The results support that the different perspectives of the two professions in combination are important for the safety of surveillance and the psychosocial support expected from antenatal care.

Background: Little is known about the contribution of maternal and paternal factors to the inverse association between birth weight and later blood pressure in human offspring. A study of within- and between-family associations of birth weight with blood pressure, which collected data on both parents, would address this gap in our knowledge., Methods and Results: The study examined families composed of mother, father, and 2 full sibs delivered between 38 and 41 weeks' gestation within 36 months of each other. A total of 1967 families meeting our inclusion criteria were contacted and 602 were examined (children 5 to 14 years old, 1998 to 2000). Birth weight and gestational age were available from obstetric records. Systolic blood pressure in childhood was inversely associated with birth weight within families (-2.3 mm Hg/kg, 95% CI -4.4 to -0.3) after adjustment for gestational age, sex, height, and weight at examination. The between-family effect (-1.5 mm Hg/kg, -3.1 to 0.0) was strengthened on adjustment for maternal and paternal height and weight, whereas adjustment for paternal and maternal systolic blood pressure at examination independently attenuated the effect., Conclusions: The existence of an inverse association of birth weight with systolic blood pressure within families (adjusted for height and weight at examination) demonstrates that factors that vary between pregnancies in the same woman (including fetal genotype) can influence the later blood pressure of offspring. We conclude that this apparent fetal programming effect on blood pressure will not be eliminated solely by interventions aimed at modifying growth and cumulative nutritional status from conception through childhood or other fixed characteristics of future mothers.

Biallelic germline mutations in the base excision repair gene MYH have been shown to predispose to a proportion of multiple colorectal adenomas and cancer. To evaluate the contribution of MYH mutations to non- FAP, non-HNPCC familial colorectal cancer, 84 unrelated Swedish individuals affected with colorectal cancer from such families were screened for germline mutations in the coding sequence of the gene. None of the cases was found to carry any pathogenic sequence change. We then determined the prevalence of the two most common pathogenic MYH mutations found in Caucasians, Y165C and G382D, in 450 Swedish sporadic colorectal cancer cases and 480 Swedish healthy controls. The frequency of both variants in Swedish cases and controls was similar to those previously reported. In addition, we found that previously unknown sequence variations at the position of amino acid 423 (R423Q, R423P, and R423R) appear to occur more frequently in cases than in controls (p = 0.02), a finding that warrants future studies.

Objective: The aims of the present study were to describe the prevalence of a number of physical symptoms, as described by women themselves, two months and one year after childbirth in a national Swedish sample and to investigate the association between specific symptoms and women's self-rated health., Design: Cohort study., Setting: Swedish antenatal clinics., Population: A total of 2413 women recruited from 593 antenatal clinics in Sweden during three one-week periods evenly spread over one year (1999-2000), representing 54% of women eligible for the study and 76% of those who consented to participate. The representativity of the sample was assessed by comparison with the total Swedish birth cohort of 1999., Methods: Data were collected by means of questionnaires in early pregnancy, two months and one year after the birth and from the Swedish Medical Birth Register., Main Outcome Measures: Self-reported symptoms and self-rated health., Results: Tiredness, headache, neck, shoulder and low back pain were common problems at two months as well as one year after childbirth. At two months, pain from caesarean section, dyspareunia and haemorrhoids were frequent problems, whereas stress incontinence was often reported at one year. Ninety-one percent of the women said self-rated health was 'very good' or 'good' at two months after birth, and 86% at one year. Low self-rated health was associated with symptoms that affected general physical functioning and wellbeing, such as tiredness, headache, musculoskeletal problems, mastitis, perineal pain, dysuria, stomachache and nausea. Complaints related to more specific situations, such as dyspareunia, constipation and stress incontinence were not associated with self-rated health., Conclusion: Despite the fact that physical symptoms were common two months and one year after the birth, the vast majority of women rated their health as 'very good' or 'good'.

Background: The aims of the present study were to describe the prevalence of stress incontinence, as described by women themselves, 1 year after childbirth in a national sample of Swedish-speaking women, and to identify possible predictors., Methods: A cohort study, including 2390 women recruited from 593 antenatal clinics in Sweden during three 1-week periods evenly spread over 1 year (1999-2000), representing 53% of women eligible for the study and 75% of those who consented to participate. Data were collected by means of questionnaires in early pregnancy, 2 months and 1 year after the birth, and from the Swedish Medical Birth Register., Results: One year after the birth, 22% of the women had symptoms of stress incontinence but only 2% said it caused them major problems. The strongest predictor was urinary incontinence (overall leakage) 4-8 weeks after a vaginal delivery (OR 5.5, CI 95% 4.1-7.4) as well as after a cesarean section (OR 11.9, CI 95% 2.9-48.1). Other predictors in women with a vaginal delivery were: multiparity (OR 1.4; CI 95% 1.1-1.8), obesity (OR 1.6; CI 95% 1.1-2.4) and constipation 4-8 weeks postpartum (OR 1.4; CI 95% 1.1-1.9)., Conclusion: Stress incontinence 1 year after childbirth is a common symptom, which could possibly be reduced by identifying women with urinary leakage at the postnatal check-up.

Health personnel volunteering for humanitarian assistance assignments work in increasingly dangerous situations and increasingly complex roles. A qualitative analysis of interviews with returning Swedish aid workers, who collectively had been on 74 missions in 32 different countries, revealed that they felt positive about their contribution, but experienced high levels of stress and frustration. They were also surprised and inadequately prepared for tasks that fell outside their professional health care training, including ones demanding pedagogic and management skills. The volunteers perceived their success on humanitarian assistance assignments as being affected not only by their own professional competence and special preparatory training, but also by many other factors. In particular, recruiting organizations could improve volunteer performance by accepting only experienced professionals, requiring special preparatory training, clarifying the exact nature of the work, and providing better support during the assignment. Further analysis of humanitarian assistance as a complex and dynamic system involving multiple 'actors' could lead to improved understanding and better performance.

From antenatal clinics in Sweden, 271 women were recruited after week 33 of pregnancy and given a questionnaire designed to assess their attitudes and feelings about the coming childbirth. Thereafter, they formulated a birth plan. The midwife in attendance at the birth was able to refer to this plan. Women who followed this program were compared with women from the same clinics who were asked to complete a questionnaire during the first postpartum week to assess their birth experience. A questionnaire at the end of pregnancy, followed by a birth plan, was not effective in improving women's experiences of childbirth. In the birth plan group, women gave significantly lower scores for the relationship to the first midwife they met during delivery, with respect to listening and paying attention to needs and desires, support, guiding, and respect. Although a birth plan did not improve the experience of childbirth in the overall group, there may be beneficial effects with regard to fear, pain, and concerns about the newborn for certain subgroups of women.

Objective: To evaluate the usefulness of prenatal risk assessment for prediction of need for obstetric interventions., Design: Area based retrospective study., Setting: Västerås Central Hospital, Sweden, with all antenatal care units in the area., Subjects: All women delivered at the only delivery ward in the area, after attending antenatal care at the affiliated ANC-units in 1990 (n = 2008) and 1992 (n = 1874)., Main Outcome Measures: Obstetric interventions at delivery., Results: During the two years 81% and 83% of the study population delivered an infant in vertex presentation at term but 15% and 17% without risk factors or complications at the end of pregnancy had complications during delivery. The relative risk for interventions when risk factors were present was 2.2 and with spontaneous onset of labor 1.3/1.4. Low risk primiparae had unforeseen complications in 25% and multiparae in 10%. Relative risk for multiparae with risk factors and spontaneous labor was 2.2/1.8 and for primiparae 1.4/1.6., Conclusions: Individual prediction of obstetric emergencies has low accuracy, which should be included in the information to women as well as in discussions with health pianners.

The treatment of rectal cancer has changed significantly during the last 30 years. With improved surgical technique and the introduction of preoperative radiotherapy sphincter preserving surgery is now predominant and the rate of local recurrence has been reduced substantially. However, new therapy concepts may also introduce an increased risk of complications. A register to monitor quality control in rectal cancer treatment in Sweden was established in 1995. It covers over 95 per cent of the patients with rectal cancer reported to the Swedish National Cancer Registry. Collection of data and validation are done by six regional oncology centres under supervision of surgeons appointed by the hospitals involved. The results are then collated to a nationwide quality register, enabling regions to compare themselves with other regions, and hospitals with other hospitals.

Background: Risk assessment is an essential component of all programs for surveillance of pregnancy. The objective of the study is to assess the usefulness of initial risk status as predictor for pregnancy complications and premature delivery., Methods: A retrospective, area-based study including all women giving birth at Västerås Central Hospital, Sweden in 1990 (2,008) and 1992 (1,874). Data was collected before and after the introduction of a reduced routine surveillance program. The study populations were classified in a low-risk group and three risk groups according to presence of risk factors at booking (initial risk factors), development of pregnancy complications (later risk factors) or a combination of both. Relative risk for premature delivery and predictive value of initial risk factors for pregnancy complications were analyzed., Results: The relative risk for premature delivery was significantly increased in all three risk categories both years except for the group with only initial risk factors in 1990. Risk factors were present at booking in 27% (1990) and 26% (1992). Pregnancy complications developed in 35% and 28%, respectively. The positive predictive value of initial risk factors for pregnancy complications was 40% and 33%, adding little useful information., Conclusion: The relative risk for premature delivery was correlated to obstetric risk but was moderately increased with initial risk factors only. The initial risk status is a poor predictor of pregnancy complications and cannot alone be used for individual planning of surveillance during pregnancy. Even for low risk women routine programs must be structured to secure adequate identification of current complications.

Objectives: To analyse which subgroups of perinatal deaths contribute most to the perinatal mortality rate in Lithuania compared with Denmark/Sweden., Design: Comparison of all perinatal deaths in Denmark/Sweden 1991 and Lithuania 1993-1994 by the common Nordic-Baltic perinatal death classification, based on information from the medical records., Results: The doubled perinatal mortality in Lithuania compared with Denmark/Sweden is mainly explained by a threefold increase of intrapartum and two- to fivefold increase in neonatal deaths of nonmalformed infants. The higher rate of malformed infants is partly explained by a four times higher mortality from neural tube defects., Conclusions: The use of a common perinatal death classification has identified categories mainly responsible for the higher rate of perinatal mortality, but further investigation of potentially avoidable factors requires further study.

Background: In 1991 the rate of intrapartum death of non-malformed fetuses was higher in Denmark than in Sweden (4.2 vs. 1.9 per 10,000, OR 2.24). However, it is not clear whether this difference reflects potentially avoidable cases and/or suboptimal care., Material and Methods: Short descriptions were made from medical records of all 50 intrapartum deaths in Denmark and Sweden in 1991. Ten obstetricians, two from each of the Nordic countries, reviewed the cases to determine whether (1) intra-uterine death might have occurred before admission, (2) surveillance and intervention were insufficient, (3) fetal death was potentially avoidable by improved obstetric care; and, if so, to suggest ways of improved health care., Results: There was a statistically higher rate of insufficient care (surveillance and intervention) (high or less degree) in the Danish cases (66% vs. 55%). The proportion of potentially avoidable fetal deaths was also higher in Denmark (59% vs. 52%) although the difference was not statistically significant., Conclusion: The significantly higher rate of intrapartum death of non-malformed infants in 1991 in Denmark compared to Sweden might be reduced by improved intrapartum surveillance and interventions.

Background: It has been suggested that the effect of maternal smoking on fetal growth is partly mediated through nutritional factors., Objective: To assess the effects of maternal smoking on birthweight in term pregnancies among mothers with different anthropometric stature., Design: A prospective study from early pregnancy of healthy parous women and their infants., Setting: Three Scandinavian university hospitals covering all deliveries from well defined geographic areas., Subjects: Smoking (774) and non-smoking (325) mothers, para 1 and 2 and with > 36 weeks gestational length., Main Outcome Measure: Birthweight., Results: Maternal age, smoking, pre-pregnancy weight, height, body mass index and pregnancy weight gain all independently influenced birthweight. Smoking mothers had significantly lower pre-pregnancy weight and lower body mass index compared to nonsmoking mothers. The negative influence of smoking on birthweight appeared to be uniformly distributed throughout all the different maternal height and weight groups., Conclusions: Birthweight was negatively related to amount cigarettes smoked per day, and no protective effect could be demonstrated from higher maternal weight, pregnancy weight gain or body mass index.

All pregnant women in Uppsala county in 1987 were questioned on three different occasions about smoking habits, socio-demographic factors and obstetric history. After delivery, information was collected regarding their children. Twenty percent of the mothers continued to smoke during pregnancy, while 8% stopped smoking. The mean birth weight of infants of smokers was 3378 g and of non-smokers 3589 g. The difference was significant (p < 0.001) and persisted after statistical adjustment for maternal age, parity and educational level. Perinatal morbidity (admission to the Department of Neonatology) was higher in the smoking group (11.4% versus 8.8%, p < 0.05). The proportion of infants with a birth weight less than 2500 g and that of small-for-gestational-age infants were 60% and 100% greater, respectively, in the smoking group. The mean birth weight and perinatal morbidity rate in infants of mothers who stopped smoking were almost identical to those in infants of non-smokers. Cessation of smoking improves foetal growth and perinatal health.

Study Objective: The aim was to study changes in smoking habits during pregnancy and differences in characteristics between women who stop smoking and those who continue to smoke during pregnancy., Design: The study was a population based prospective study. Self administered questionnaires were completed on three occasions., Setting: The study area was Uppsala county, Sweden, in 1987., Participants: The participants were women registered with antenatal care clinics, which included all pregnant women in the county. Ninety six percent (n = 3678) of all pregnant women completed the first questionnaire. Thirty two percent of these were smokers at time of conception., Measurements and Main Results: Twenty nine percent of the smokers stopped smoking at some stage of pregnancy, and the majority did so before having registered for antenatal care. Using logistic regression analysis it was found that high parity number, not living with infant's father, heavy smoking, and daily passive smoking at home were associated with significantly increased risk for continued smoking during pregnancy. High level of education and high age at onset of smoking decreased the risk., Conclusions: In order to reduce the smoking related risks for unsuccessful pregnancy outcome, general preventive efforts in society must be combined with the development of more specialised antenatal programmes designed with consideration of the characteristics and life situation of the pregnant smoker.

The Swedish routine program for antenatal care is based on a number of scheduled visits for the detection of symptomless complications, as well as psychosocial support and health education. The scientific evidence to support the present timing and contents of routine visits is unsatisfactory, and there is a great need for evaluation both of single diagnostic procedures and interventions and of programs of antenatal care.

During 3 years of continuous screening for gestational diabetes mellitus in the county of Uppsala, 133 pregnant women (1.2%) were given this diagnosis. Maternal characteristics and the perinatal outcome of the pregnancies were examined retrospectively. Maternal overweight [body mass index greater than 23.9 kg/(m)2] was noted in 54.9% of the 133 women. Insulin therapy, with a mean daily dose of 42 U, was given to 62.4% of the patients, whereas the others were given dietary instructions alone. The frequency of infants with a birth weight greater than 2 SD was 24.1% and was significantly (p less than 0.025) related to pre-pregnancy overweight and also to pregnancy weight gain 18kg (p less than 0.01). Caesarean section was performed in 27% of the pregnancies complicated by diabetes, compared with the overall figure of 11% in Uppsala during the study period. Neonatal hypoglycaemia (blood glucose greater than or equal to 1.6 mM) was noted in 17.3% of the infants and was significantly (p less than 0.01) related to maternal sympathomimetic therapy. Despite liberal and intensive insulin therapy, there was a considerable rate of perinatal complications. Although not severe, they indicate a need for further improvement in the care of women with gestational diabetes.

Incidence figures for hypertensive disease in pregnancy (HDP) vary widely in epidemiological studies due to variations in definitions, the occurrence of risk factors and differing methods of data collection. In Uppsala county all pregnant women with a diastolic blood pressure of 90 mmHg or more were prospectively registered within a 2-year-period. The incidence of hypertension noted in the antenatal clinics was found to be 7.2%. In 56% of the cases hypertension was first noted after 37 weeks of gestation. The group of patients presenting before term with hypertension not normalized by bed rest in hospital and without complicating factors was only 14% of the whole material. The implications of the findings for discussions on therapy and complications in HDP are discussed.

Among 480,969 births in Sweden during the period 1976 to 1980, 74 parturients with eclampsia were identified. The clinical characteristics of women developing eclampsia before 37 completed weeks of gestation differed markedly from those with eclampsia at term. In the pre-term group, subjective symptoms nearly always preceded the eclamptic attack, the newborns were generally small-for-gestational-age, the perinatal mortality was high, and the mothers more frequently had complications related to eclampsia. The only maternal death occurred in this group. In the term group the first convulsion often came unexpectedly without typical premonitory signs. The infants were with few exceptions within the average for gestational age. The general outcome for mothers and their babies was favorable and the length of hospital stay was on average 3 days longer than that of the overall obstetric population. Eclampsia cases in Sweden represent a small subfraction of parturients with hypertensive disorders of pregnancy. The incidence (29/100,000) in our material is, to our knowledge, the lowest yet reported. Despite the very regular attendance at the antenatal clinic, weekly from 36 weeks onwards, fewer than half of the patients had hypertension diagnosed 4 days or more prior to the eclamptic convulsion. A shortening of the intervals between the antenatal visits therefore does not seem warranted.

The study "Successive Small-for-Gestational Age Births" (SGA study) was initiated and is sponsored by the National Institutes of Health (N.I.H.) in the U.S.A. Its purpose is to describe and characterize the different types of intra-uterine growth retardation and their consequences, to assess the associated risk factors, and to provide a basis for preventive measures. Starting in 1986, it runs concurrently in Bergen and Trondheim (Norway), Uppsala (Sweden) and Birmingham, Alabama (U.S.A.), recruiting pregnant para 1 and 2 mothers at high risk of having an SGA birth and a random (control) sample of the total pregnant population. Data collection will end in late 1989, when the last-born children have reached 13 months of age. At the present symposium, investigators from all four study centers and the N.I.H. described the study design and discussed problems of methodology. Strict standardization of parameters to determine gestational age (ultrasound, menstrual dates) is a prerequisite for comparison of results over time and between study centers. Some preliminary results were presented.

When an early postnatal discharge program was introduced in Falun, Sweden in 1984, with early discharge defined as discharge 24-48 hours after birth combined with home visits on the following days, an investigation into background characteristics of parents choosing to participate and not to participate in the evaluative study of the program was initiated. 164 participants were compared with 354 non-participants. Data were collected mainly from questionnaires, 8 weeks before term. The participants were a more heterogeneous group than was expected when starting the program. Compared with the non-participants, they were characterized by: a less positive attitude to post-partum care in hospital and greater self-confidence in terms of confidence when thinking of birth and parenthood. They were more often multipara and had experienced rather less complicated pregnancies. They were a little younger and somewhat less well educated as a group, but the proportion of well educated women was the same as among non-participants. They had attended antenatal classes this pregnancy to a lesser extent, but felt better prepared for the delivery. They had a greater number of supportive persons available in case of early discharge. There was no difference between participants and non-participants as regards economy, housing conditions, distance to hospital, proportion of immigrants, paternal interest in childbirth and parenthood, equality in parental relations, social contacts, and leisure activities.

During the five-year period 1964-68 96 733 births were registered in the 28 hospitals equipped with maternity facilities in the Uppsala hospital region. Of these babies, 1 636 were born in 818 twin deliveries. Data on gestational age, sex, weight and length at birth, birth order, hospital type, congenital malformations and perinatal mortality are analysed. Altogether 17.3 per 1 000 of the children born during this period were born in multiple births. The perinatal mortality for the twin babies was 64 per 1 000 born, with the mortality higher in the less specialized hospitals than the others. Twin no. 1 suffered perinatal death in 67 cases per 1 000 and twin no. 2 in 60 cases per 1 000. For twins of primiparae the losses were 92 per 1 000 children and for twins born to multiparae 51 per 1 000. Altogether 72 per 1 000 male twins died perinatally compared to 52 per 1 000 female twins. The most heavy losses occurred among the low-weight premature twins and in these cases both twins often suffered perinatal death.

In a prospective clinical study from Uppsala County, Sweden, in 1980, all pregnancies were screened early in pregnancy for 15 previously reported risk factors for intrauterine growth retardation (IUGR). This risk group (n = 639) was then compared with a randomly selected control group (n = 539). In the risk group, there were increased risks for the delivery of growth retarded infants, low birthweight infants and infants spontaneously delivered as prematures. 30% of the population exhibited risk factors. Smoking was the most important risk factor, 16% of the mothers smoked at least ten cigarettes per day and smoking was the main risk factor in the majority of cases with IUGR.