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  • 1. Bäck, Lena
    et al.
    Sharma, Bharati
    Karlström, Annika
    Tunón, Katarina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Östersunds sjukhus, kvinnosjukvården, Östersund, Sweden.
    Hildingsson, Ingegerd
    Professional confidence among Swedish final year midwifery students: a cross-sectional study2017In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 14, p. 69-78Article in journal (Refereed)
    Abstract [en]

    Objective: Previous international studies have shown that midwifery students do not feel confident in many areas where they are supposed to practice independently. Objective: The knowledge about Swedish midwifery students' confidence is fairly under investigated. The purpose of the present study was to explore final years' midwifery students' professional confidence in basic midwifery skills according to ICM competencies and associated factors. Methods: A cross-sectional survey where all midwifery programs in Sweden were invited to participate. Data was collected by a questionnaire that measured midwifery students self-reported assessment of confidence against four selected domains of ICM competencies; antenatal, intrapartum, postpartum and new-born care. Result: The main findings of this study showed that Swedish midwifery students were confident in managing normal pregnancy, labour and birth. Midwifery students at a school with a medical faculty were more confident in handling obstetric emergency situations. Some background variables were also associated with confidence. Conclusion: This study highlighted some midwifery skills that needs further training and reflection. More training and developing confidence in complicated and emergency situations are needed. There seem to be a need of midwifery education reforms if we believe that high levels of confidence at the time of graduation is equal to competent and skilled midwives in the future.

  • 2.
    Edblad-Svensson, Ann
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Silfverdal, Lena
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Collberg, Pia
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Tunón, Katarina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    High-Risk Types of Human Papilloma Virus DNA Testing in Women with False Negative Cytology2018In: Acta Cytologica, ISSN 0001-5547, E-ISSN 1938-2650, Vol. 62, no 5-6, p. 411-417Article in journal (Refereed)
    Abstract [en]

    Objective: To determine whether high-risk types of human papilloma virus (hrHPV) DNA testing is reliable for selection patients in need of further investigation with colposcopy in women with increased risk of high-grade cervical lesions as a result of false negative cytology. The secondary objective was to compare the sensitivity of hrHPV testing on self-collected versus physician-collected samples for the detection of histological high-grade cervical intraepithelial neoplasia (CIN2+). Methods: Sixty-three patients identified with a missed abnormality following the re-evaluation of benign cervical cytology were included. A patient-collected and a physician-collected sample for HPV, colposcopy and cervical specimen collection for histology and cytology were performed. Results: The sensitivity of hrHPV testing of physician-collected samples for CIN2+ was 100% (95% CI 82.7-100), and the negative predictive value (NPV) was 100% (95% CI 93.3-100). The sensitivity of the self-sampling device to identify CIN2+ was 84.6% (95% CI 59.1-96.7), and the NPV was 94.4% (95% CI 83.4-98.8). The differences in the sensitivity and NPV between the 2 methods were non-significant. The agreement between the 2 methods regarding the HPV results was good, with a kappa value of 0.74 (95% CI 0.57-0.91). Conclusion: The current findings indicate that physician-collected samples for hrHPV DNA testing may be used as triage for the colposcopy of women with false negative cytology.

  • 3.
    Huber, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Larsson, Charlotta
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Harrysson, Mathilda
    Department of Obstetrics and Gynecology, Östersund Hospital, Östersund, Sweden.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Lehmann, Jan-P.
    Department of Surgery, Östersund Hospital, Östersund, Sweden.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Tunón, Katarina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Use of endoanal ultrasound in detecting obstetric anal sphincter injury immediately after birth2023In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 102, no 3, p. 389-395Article in journal (Refereed)
    Abstract [en]

    Introduction: Obstetric anal sphincter injury (OASI) complicates around 5% of deliveries in primiparas. The study objective was to assess the utility of three-dimensional endoanal ultrasonography (3D-EAUS) in the diagnosis of OASI.

    Material and methods: The present study was designed to mirror screening settings with an unselected cohort of nulliparous women. All enrolled patients underwent clinical examination of the perineum by the caregiver, and 3D-EAUS was conducted. Post-processing of ultrasonography volume data was performed by an experienced colorectal surgeon who was blinded to all other data. The sensitivity, specificity, negative predictive value, and positive predictive value of 3D-EAUS in the diagnosis of OASI was evaluated. The trial is registered at ISCRTN: 18006769.

    Results: A total of 680 scans were performed, of which 18.5% were judged as “non-assessable”, resulting in 554 assessable recordings. Sphincter defects were observed in 12.8% of all assessable recordings on 3D-EAUS (n = 71). With clinical examination set as the reference standard, ultrasound sensitivity in the diagnosis of OASI was 30.4%, whereas its specificity was 87.9%. The negative predictive value was 96.7% and the positive predictive value was only 9.9%. Comments were left on 175 examinations, of which 74% referred to the management of the examination.

    Conclusions: Using 3D-EAUS in a maternity ward is demanding because staff generally have little experience in endoanal ultrasound, which contributes to difficulties in obtaining good image quality. When 3D-EAUS is performed to mirror screening settings, it adds no convincing diagnostic power to clinical examination in the diagnosis of OASI.

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  • 4.
    Huber, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Larsson, Charlotta
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Lehmann, Jan-P
    Department of Surgery, Östersund Hospital, Östersund, Sweden.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Lindam, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Tunón, Katarina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Sonographic postpartum anal sphincter defects and the association with pelvic floor pain and dyspareunia2023In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 102, no 10, p. 1290-1297Article in journal (Refereed)
    Abstract [en]

    Introduction: Pelvic floor pain and dyspareunia are both important entities of postpartum pelvic pain, often concomitant and associated with perineal tears during vaginal delivery. The association between postpartum sonographic anal sphincter defects, pelvic floor pain, and dyspareunia has not been fully established. We aimed to determine the prevalence of postpartum anal sphincter defects using three-dimensional endoanal ultrasonography (3D-EAUS) and evaluate their association with symptoms of pelvic floor pain and dyspareunia.

    Material and methods: This prospective cohort study followed 239 primiparas from birth to 12 months post delivery. Anal sphincters were assessed with 3D-EAUS 3 months postpartum, and self-reported pelvic floor function data were obtained using a web-based questionnaire distributed 1 year after delivery. Descriptive statistics were compared between the patients with and without sonographic defects, and the association between sonographic sphincter defects and outcomes were analyzed using logistic regression.

    Results: At 3 months postpartum, 48/239 (20%) patients had anal sphincter defects on 3D-EAUS, of which 43 (18%) were not clinically diagnosed with obstetric anal sphincter injury at the time of delivery. Patients with sonographic defects had higher fetal weight than those without defects, and a perineum <2 cm before the suture was a risk factor for defects (odds ratio [OR], 6.9). Patients with sonographic defects had a higher frequency of dyspareunia (OR, 2.4), and pelvic floor pain (OR, 2.3) than those without defects.

    Conclusions: Our results suggest an association between postpartum sonographic anal sphincter defects, pelvic floor pain, and dyspareunia. A perineal height <2 cm, measured by bidigital palpation immediately postdelivery, was a risk factor for sonographic anal sphincter defect. We suggest offering pelvic floor sonography around 3 months postpartum to high- risk women to optimize diagnosis and treatment of perineal tears and include perineum <2 cm prior to primary repair as a proposed indication for postpartum follow-up sonography.

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  • 5.
    Huber, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Larsson, Charlotta
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Lehmann, Jan-Peter
    Department of Surgery, Östersund Hospital, Östersund, Sweden.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Lindam, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Östersund Hospital, Östersund, Sweden.
    Tunón, Katarina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    The prevalence of postpartum anal sphincter defects and the association with perineal pain and dyspareuniaManuscript (preprint) (Other academic)
  • 6.
    Huber, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Malers, Ellen
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Tunón, Katarina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Pelvic floor dysfunction one year after first childbirth in relation to perineal tear severity2021In: Scientific Reports, E-ISSN 2045-2322, Vol. 11, no 1, article id 12560Article in journal (Refereed)
    Abstract [en]

    The aims of this study were to evaluate pelvic floor dysfunction symptoms one year after delivery and investigate whether adverse functional outcomes after childbirth were related to the degree of perineal injury. A prospective cohort of 776 primiparas were included. Self-reported pelvic floor function data were obtained using a web-based questionnaire. Women with no/first-degree injuries, second-degree injuries, third-/fourth-degree injuries (obstetric anal sphincter injury, OASI) and cesarean section were compared. A total of 511 women (66%) responded. Second-degree tears were a risk factor for stress incontinence (aOR 2.6 (95% CI 1.3–5.1)). Cesarean section was protective against stress incontinence (aOR 0.2 (95% CI 0.1–0.9)). OASI was a risk factor for urge incontinence (aOR 4.8 (95% CI 1.6–15)), prolapse (aOR 7.7 (95% CI 2.1–29)) and pelvic pain (OR 3.3 (95% CI 1.1–10)). Dyspareunia was reported by 38% of women, 63% of women in the OASI group (aOR 3.1 (95% CI 1.1–9.0)). Women with OASI reported that the injury affected daily life (OR 18 (95% CI 5.1–59)). Pelvic floor dysfunction is common after childbirth, even in women with moderate injury. Women with OASI had significantly higher risks of symptoms of prolapse, urge urinary incontinence, pain, dyspareunia and impacts on daily life.

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  • 7.
    Huber, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Tunón, Katarina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Lindqvist, Maria
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Umeå University, Faculty of Medicine, Department of Nursing.
    "From hell to healed" - A qualitative study on women's experience of recovery, relationships and sexuality after severe obstetric perineal injury2022In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 33, article id 100736Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Few studies have investigated women's experiences of daily life after childbirth complicated by obstetric anal sphincter injury (OASI). The aim of the present study was to explore experiences related to recovery, sexual function, relationships and coping strategies among women affected by OASI.

    METHODS: In-depth interviews were conducted using a purposive sample of 11 women affected by OASI. Women were interviewed 1-2 years after their first childbirth. Inductive qualitative content analysis was applied.

    RESULTS: The theme "From hell to healed" illustrates women's experiences of recovery, relationships and sexual function after OASI. Three categories addressing women's perceptions emerged: "Challenged to the core", "At the mercy of the care provider" and "For better or for worse". Support from partners and family and comprehensive care were important elements for the experiences of coping and healing from OASI. Elements that negatively influenced women's experiences were the pain and physical symptoms of pelvic floor dysfunction, normalization of symptoms by heath care providers, and unrealistic expectations about how this period in life should be experienced.

    CONCLUSION: OASI greatly affects women's experiences of their first years with their newborn child, relationships, social context and sexuality. For some women, OASI negatively affects everyday life for a long period after childbirth. However, others heal and cope quite quickly. Health care professionals need to identify and pay attention to women with persisting problems after OASI so that they can be directed to the right level of care.

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  • 8.
    Larsson, Charlotta
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Hospital of Östersund, Östersund, Sweden.
    Hedberg, Charlotta Linder
    Lundgren, Ewa
    Söderström, Lars
    Tunón, Katarina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Anal incontinence after caesarean and vaginal delivery in Sweden: a national population-based study2019In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 393, no 10177, p. 1233-1239Article in journal (Refereed)
    Abstract [en]

    Background: Elective caesarean delivery is increasing rapidly in many countries, and one of the reasons might be that caesarean delivery is widely believed to protect against pelvic floor disorders, including anal incontinence. Previous studies on this issue have been small and with conflicting results. The aim of present study was to compare the risk of developing anal incontinence in women who had a caesarean delivery, in those who had a vaginal delivery, and in two age-matched control groups (nulliparous women and men).

    Methods: In this observational population-based study, we included all women in the Swedish Medical Birth Register who gave birth by caesarean delivery or vaginal delivery during 1973-2015 in Sweden and were diagnosed with anal incontinence according to ICD 8-10 in the Swedish National Patient Register during 2001-15. Exclusion criteria were multiple birth delivery, mixed vaginal and caesarean delivery, and four or more deliveries. We compared the diagnosis of anal incontinence between women previously delivered solely by caesarean delivery and those who solely had delivered vaginally. We also compared it with two age-matched control groups of nulliparous women and men from the Swedish Total Population Register. Finally, we analysed risk factors for anal incontinence in the caesarean delivery and vaginal delivery groups.

    Findings: 3 755 110 individuals were included in the study. Between 1973 and 2015, 185 219 women had a caesarean delivery only and 1 400 935 delivered vaginally only. 416 (0.22 %) of the 185 219 women in the caesarean delivery group were diagnosed with anal incontinence compared with 5171 (0.37%) of 1 400 935 women in the vaginal delivery group. The odds ratio (OR) for being diagnosed with anal incontinence after vaginal delivery compared with caesarean delivery was 1 center dot 65 (95% CI 1 center dot 49-1 center dot 82; p<0.0001). When the combination vaginal delivery and caesarean delivery was compared with the nulliparous control group, the OR of being diagnosed with anal incontinence was 2 center dot 05 (1 center dot 92-2 center dot 19; p<0.0001). For the nulliparous women compared with men, the OR for anal incontinence was 1 center dot 89 (1 center dot 75-2 center dot 05; p<0.0001). The strongest risk factors for anal incontinence after vaginal delivery were high maternal age, high birthweight of the child, and instrumental delivery. The only risk factor for anal incontinence after caesarean delivery was maternal age.

    Interpretation: The risk of developing anal incontinence increases after pregnancy and delivery. Women with known risk factors for anal incontinence should perhaps be offered a more qualified post-partum examination to enable early intervention in case of injury. Further knowledge for optimal management are needed. Copyright (c) 2019 Elsevier Ltd. All rights reserved.

  • 9.
    Larsson, Charlotta
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Östersund Hospital, Östersund, Sweden.
    Matsson, Anton
    Hospital of Östersund, Östersund, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Söderström, Lars
    Department of Research and Development, Hospital of Östersund, Östersund, Sweden.
    Tunón, Katarina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Östersund Hospital, Östersund, Sweden.
    Cardiovascular complications following cesarean section and vaginal delivery: a national population-based study2022In: The Journal of Maternal-Fetal & Neonatal Medicine, ISSN 1476-7058, E-ISSN 1476-4954, Vol. 35, no 25, p. 8072-8079Article in journal (Refereed)
    Abstract [en]

    Introduction: Rates of cesarean section are rising in both developed and developing countries and while pregnancy and cesarean section are established as risk factors for thromboembolism and stroke, large population-based investigations focusing on all types of cardiovascular complication after delivery is missing. The aim was to analyze the risk of severe cardiovascular complications in the post-partum period following delivery by cesarean section. We also had a control group of vaginal deliveries and a reference group with nulliparas.

    Materials and Methods: This Swedish population-based study used three national registers between 2005 and 2017 and comprised a total of 1 165 684 individuals. Unselected register data was cross-linked and cardiovascular adverse events were identified by ICD diagnosis codes. 140 128 women (209 391 deliveries) were included in the cesarean group and 614 355 women (973 429 deliveries) in the vaginal control group. The reference group comprised 411 201 age-matched nulliparous women. The primary analysis was the risk of severe cardiovascular complications within 42 days of cesarean section or vaginal delivery. The secondary analysis evaluated risk factors for cardiovascular complications.

    Results: In the cesarean section group, 410 (0.20%) had a serious cardiovascular event within 42 days after delivery, and in the vaginal control group the number was 857 (0.09%). The risk of having an adverse cardiovascular event was significantly greater in the cesarean group (OR 2.23, CI 1.98 to 2.51) for all types of cardiovascular events. Risk factors were high BMI, preeclampsia, greater maternal age, tobacco use and acute cesarean delivery.

    Conclusions: The absolute numbers on severe maternal morbidity after delivery are low. However, since almost half of the world’s population are affected and the frequency of elective cesarean section continues to rise, a doubling of the risk for a severe cardiovascular event within 42 days of delivery is important to consider globally.

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  • 10.
    Rensfeldt, Frida
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Huber, Malin
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Tunón, Katarina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Causes of death in stillbirth and quality of care: an example of a local audit2023In: Reproductive, Female and Child Health, ISSN 2768-7228, Vol. 2, no 1, p. 33-39Article in journal (Refereed)
    Abstract [en]

    Introduction: Neonatal deaths have decreased steadily in Sweden since the 1960s, but the stillbirth rate has been stable at around 4 per 1000 births, for the last 40 years. Risk factors of stillbirth are well studied; however, the cause of death is unclear in many cases. The purpose of this study was to examine causes of death in stillbirth using a classification system. In addition, we aimed to assess substandard care factors and identify areas for quality improvement.

    Materials and Methods: We performed a retrospective clinical audit of all stillbirths delivered between January 2006 and December 2019. We performed a detailed investigation of medical records and classified the causes of death according to ‘The Stockholm classification of stillbirth’. Unclear cases were discussed in a multidisciplinary local audit group. Substandard care factors were identified and classified as probable, possible, or unlikely, with respect to the cause of death.

    Results: In total, there were 64 cases of stillbirth. It was possible to determine a cause of death in 91% (95% confidence interval [CI]: 81.02–95.63) of the cases. The leading cause of death was intrauterine growth restriction (IUGR)/placental insufficiency (45%) (95% CI: 33.73–57.43), followed by infection (13%) (95% CI: 6.47–22.8) and placental abruption (9%) (95% CI: 4.37–18.98). Factors of substandard care were identified in 49% (95% CI: 37.06–61.4) of the cases, but in only 10% the substandard care factor had a probable association with the cause of death.

    Conclusion: Introducing a local audit group and using a validated classification system made it possible to find a cause of death in about 90% of the cases of stillbirth. Since IUGR/placental insufficiency is the leading cause of death, it is important to improve current strategies to identify pregnancies at risk for IUGR, antenatally. Our results suggest that there is a possibility to improve the quality of care in many areas, particularly regarding symphysis-fundus measurements.

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  • 11.
    Rydberg, Catharina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Tunón, Katarina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Detection of fetal abnormalities by second-trimester ultrasound screening in a non-selected population2017In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 96, no 2, p. 176-182Article in journal (Refereed)
    Abstract [en]

    IntroductionThis study assessed the sensitivity of routine ultrasound examination for the detection of abnormal chromosomes and structural malformations in fetuses in the second trimester in a non-selected population. Material and methodsPrenatal diagnoses of fetal abnormalities in 10 414 fetuses and newborns were reviewed and compared with all postnatal diagnoses of congenital abnormalities between 2006 and 2013. ResultsOverall, 243 fetuses and newborns had confirmed congenital abnormalities, with a prevalence of 2.3%. Of these fetuses and newborns, 23% (56/243) had chromosomal abnormalities (overall prevalence 0.5%), and 77% (187/243) had normal chromosomes with either major (44%; 82/187) or minor (56%; 105/187) structural malformations (overall prevalence 1.8%). One hundred and seven abnormalities were detected prenatally, yielding a total sensitivity for prenatal detection of fetal abnormalities of 44.0% (107/243; 95% CI 37.8-50.2), with specificity of 99.9%, a positive predictive value of 94.7%, and a negative predictive value of 98.7%. The sensitivity for prenatal detection before 22 weeks of gestation was 40.3% (98/243; 95% CI 34.1-46.5). The prenatal detection rate of chromosomal abnormalities was 60.7% (34/56) and, for structural malformations, was 39.0% (73/187). ConclusionsIn a routine clinical setting at a county hospital with a non-selected population, half of the major structural malformations in chromosomally normal fetuses are detected by routine ultrasound examination in the second trimester. Chromosomal abnormalities have the highest probability for prenatal detection; the majority are diagnosed by amniocentesis before the routine ultrasound examination in high-risk women.

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