| 1. |
- Wolgast, Emelie, et al.
(författare)
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The impact of major depressive disorder and antidepressant medication before and during pregnancy on obstetric and neonatal outcomes : A nationwide population-based study
- 2021
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Ingår i: European Journal of Obstetrics, Gynecology, and Reproductive Biology. - : Elsevier. - 0301-2115 .- 1872-7654. ; 257, s. 42-50
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To investigate the impact of major depressive disorder (MDD) and antidepressant medication before and during pregnancy on obstetric and neonatal outcomes. Study design: A national register-based cohort study of pregnant women born in Sweden, and their first child born in 2012-2015 (n = 262 329). Women diagnosed with MDD and who had redeemed an antidepressant one year before becoming pregnant ("before pregnancy") and women who were diagnosed with MDD and who had redeemed an antidepressant both before and during pregnancy ("before and during pregnancy") were compared with each other and with women who had neither been diagnosed with MDD nor been prescribed antidepressants (population controls). Results: In comparison to population controls, the "before pregnancy" and the "before and during pregnancy" groups had increased likelihoods of operative childbirth (aOR = 1.19, 95 % CI 1.12-1.27, aOR = 1.38, 95 % CI 1.28-1.48 respectively), and with an increased likelihood for the child being admitted to a neonatal intensive care unit (NICU) (aOR = 1.51, 95 % CI 1.17-1.95, aOR = 1.55, 95 % CI 1.14-2.11). Children born to mothers in the "before and during pregnancy" group had an increased likelihood of preterm birth (aOR = 1.72, 95 % CI 1.52-1.95,), while children to mothers in the "before pregnancy" group had an increased likelihood of low birthweight (aOR = 1.15, 95 % CI 1.00-1.33) compared to population controls. Women in the "before and during pregnancy" group had an increased likelihood for hyperemesis during pregnancy (aOR =1.93, 95 % CI = 1.60-2.32), having an operative childbirth (aOR =1.17, 95 % CI = 1.06-1.29) or a preterm birth (aOR = 1.53, 95 % CI = 1.28-1.81) compared to the "before pregnancy" group. Conclusions: Women with MDD and antidepressant medication prior to becoming pregnant are at increased risk for adverse obstetric and neonatal outcomes compared to women without an MDD. Continuation of antidepressant medication during pregnancy somewhat increased the risk for adverse obstetric and neonatal outcomes. (C) 2020 Published by Elsevier B.V.
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| 2. |
- Baldvinsdottir, Tinna, et al.
(författare)
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Improved clinical management but not patient outcome in women with postpartum haemorrhage-An observational study of practical obstetric team training
- 2018
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Ingår i: PLOS ONE. - : PUBLIC LIBRARY SCIENCE. - 1932-6203. ; 13:9
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Tidskriftsartikel (refereegranskat)abstract
- Objective Postpartum haemorrhage (PPH) is the most common obstetric emergency. A well-established postpartum haemorrhage protocol in the labour ward is crucial for effective treatment. The aim of the study was to investigate if practical obstetric team training improves the patient outcome and clinical management of PPH. Setting The practical obstetric team training (PROBE) at Linkoping University Hospital, Sweden, with approximate 3000 deliveries annually, was studied between the years of 2004-2011. Each team consisted of one or two midwives, one obstetrician or one junior doctor and one nurse assistant. Emergency obstetrics cases were trained in a simulation setting. PROBE was scheduled during work hours at an interval of 1.5 years. Population Pre-PROBE women (N = 419 were defined as all women with vaginal birth between the years of 2004-2007 with an estimated blood loss of amp;gt;= 1000 ml within the first 24 hours of delivery. Post-PROBE women (N = 483) were defined as all women with vaginal birth between the years of 2008-2011 with an estimated blood loss of amp;gt;= 1000 ml within the first 24 hours of delivery. The two groups were compared regarding blood loss parameters and management variables using retrospective data from medical records. Results No difference was observed in estimated blood loss, haemoglobin level, blood transfusions or the incidence of postpartum haemorrhage between the two groups. Post-PROBE women had more often secured venous access (pamp;lt;0.001), monitoring of vital signs (pamp;lt;0.001) and received fluid resuscitation (pamp;lt;0.001) compared to pre-PROBE women. The use of uterine massage was also more common among the post-PROBE women compared with the pre-PROBE women (pamp;lt;0.001). Conclusion PROBE improved clinical management but not patient outcome in women with postpartum haemorrhage in the labour ward. These new findings may have clinical implications since they confirm that training was effective concerning the management of postpartum haemorrhage. However, there is still no clear evidence that simulation training improve patient outcome in women with PPH.
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| 4. |
- Möller, Louise, 1989-
(författare)
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Health, obstetric outcomes and reproduction in women with vulvar pain or primary fear of childbirth
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Fear of childbirth (FOC) is common and affects approximately 5-20 % of all pregnant women. FOC is associated with giving birth by caesarean section on maternal request (CSMR). The rate of caesarean sections (CS) and CSMR has increased during the last decades. To decrease these women’s fear, the rate of CSMR and to promote a more positive birth experience, many treatments for FOC have been evaluated. In Sweden, the treatment is individualized and given by obstetricians, midwives, psychologists or psychotherapists in the specialist care.Women with FOC suffer more often from psychiatric illness and rate their general health as less good, which is important to consider when counselling these women and deciding on mode of delivery. Little is known about the long term obstetric and reproductive outcomes for women with FOC. Therefore, the aim of the studies on which this thesis is based was to compare psychiatric care before and after childbirth in women giving birth by CSMR to women giving birth by other modes of delivery and to follow the subsequent obstetric and reproductive outcomes in women receiving counselling for FOC in their first childbirth. Furthermore, we hypothesized that women with localized provoked vulvodynia (LPV) and/or vaginismus might fear vaginal childbirth and little is known about their reproduction and obstetric outcomes which is why we investigated the parity and obstetric outcomes in women diagnosed with LPV/vaginismus before first childbirth.Based on data linked from several Swedish National registers, the prevalence of psychiatric in- and outpatient care before (paper I) and after first childbirth (paper II) was compared in primiparae giving birth by CSMR to primiparae giving birth by other modes of delivery. The prevalence of psychiatric disorders was found to be significantly higher in women giving birth by CSMR, indicating a severe burden of psychiatric illness in these women.In paper III, also based on data from several Swedish National registers, a diagnosis of LPV/vaginismus before childbirth was shown to decrease the odds of giving birth. When giving birth these women had an increased risk of CS, especially CSMR. This could possibly indicate FOC in these women. Further, women with vaginismus had an increased risk of pelvic floor injuries.Paper IV was a follow-up study of women who received counselling for FOC in their first pregnancy leading to parturition. It was based on data from medical records and a questionnaire. The women were followed 7-14 years after their first childbirth. Women treated for FOC more often gave birth by CS, rated their first birth experience as less positive and more often required counselling for FOC in their subsequent pregnancies compared to women without FOC in their first pregnancy. There were no significant differences in the rate of complications during pregnancy and childbirth compared to the other women. Women treated for FOC less often gave birth more than twice. Despite being given counselling and being exposed to childbirth almost one in five women felt fearful towards childbirth 7-14 years after the first childbirth.In conclusion, women with FOC are a vulnerable group suffering from a significant burden of psychiatric illness. FOC is not easily treated; many women require counselling in subsequent pregnancies and many still fear childbirth after the childbearing years. Furthermore, LPV/vaginismus is a risk factor for giving birth by CSMR, possibly indicating FOC, and these women are less likely to give birth. Our study shows it is important not only to address sexual function in these women but reproductive function as well. Further studies are needed to establish how to optimize their care regarding fertility, antenatal, obstetric and post-partum care.
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| 5. |
- Nevander, Sofia, 1979-
(författare)
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Hyperglycemia in pregnancy : diagnostics and duration of labor
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objectives: The overall aim of this thesis was to evaluate the impact of maternal hyperglycemia in pregnancy on the duration of active labor, to evaluate indications for cesarean section and further, to examine cut-offs for gestational diabetes mellitus diagnosis based on capillary sampling.Material and methods: Study I was a cross-sectional study on diagnostic accuracy performed at an antenatal care clinic at the University Hospital in Linköping, Sweden. The study included 175 women undergoing an oral glucose tolerance test (OGTT) and aimed to compare capillary and venous sampling in the diagnosis of gestational diabetes mellitus (GDM) using Accu-Chek Inform II.Studies II and III were population-based, nationwide, Swedish register studies using data from the Swedish Pregnancy Register (SPR). In these, 247 524 primiparous women who delivered a singleton fetus, ≥34+0 (completed gestational weeks + additional days) with a cephalic presentation between 1 January 2014 and 30 May 2020 and had their data available in the SPR were included. Time in active labor was compared between women with GDM and women without diabetes (study II) and between women with type 1 diabetes and women without diabetes (study III) using Kaplan- Meier survival analysis and Cox regression analysis.In study III, we also evaluated indications for elective and emergency cesarean section (CS) in women with type 1 diabetes and women without diabetes.Results: In study I, the cut-offs for a GDM diagnosis using capillary samples were corrected from 5.1 to 5.3 mmol/L for the fasting sample, from 10.0 to 11.1 mmol/L for the 1 h sample and from 8.5 to 9.4 mmol/L for the 2 h sample using half of the dataset. Applying these cut-offs to the remaining dataset resulted in a sensitivity, specificity and accuracy of 85.0%, 95.0% and 90.3% respectively, with a positive predictive value (PPV) of 83%, a negative predictive value (NPV) of 96% and a positive likelihood ratio (LHR) of 16.4 using capillary sampling for the GDM diagnosis at fasting and 2-h.In study II, women with GDM had a significantly longer time in active labor, both with a spontaneous onset and induction of labor compared to women without diabetes. Women with GDM also had a decreased chance of vaginal delivery at a certain time-point compared to women without diabetes, with an adjusted hazard ratio (aHR) of 0.92 (0.88- 0.96) and 0.83 (0.76-0.90) for those with spontaneous onset and induction of labor respectively. Women with GDM had an increased risk for time in active labor ≥12 h both in spontaneous labor onset (adjusted odds ratio (aOR) 1.14 (1.04-1.25)) and in induction of labor (aOR 1.55 (1.28-1.87)).Women with type 1 diabetes had a significantly longer time in active labor, both in spontaneous onset and induced labor compared to women without diabetes. They also had a decreased chance of vaginal delivery at a certain time-point compared to women without diabetes with an aHR of 0.65 (0.60-0.70). The total rate of CS was 34.6% in the group of women with type 1 diabetes and 9.5% in the group of women without diabetes (both elective and emergency CS). The most common indication for elective CS among women with type 1 diabetes was suspected macrosomia (50.4%) whereas the corresponding number was 8.7% among women without diabetes. For emergency CS, the most common indication was fetal distress in women with type 1 diabetes (31.9%) and the corresponding number in women without diabetes was 35.9%.Conclusions: Regarding the diagnosis of GDM, we propose that capillary fasting and 2-hour post-prandial glucose samples, analyzed using the Accu-Chek Inform II system, could be used for the diagnosis of GDM during pregnancy. This approach would involve the use of adjusted cut-off values and demonstrates an acceptable level of accuracy within an antenatal care setting. It is imperative to obtain duplicate samples in order to maintain adequate precision. Furthermore, it is advisable to continue with the OGTT when the fasting samples fall within the normal range, as this leads to a greater number of women receiving a GDM diagnosis.Regarding time in active labor, both women with GDM and type 1 diabetes seemed to spend a longer time in active labor and were less likely to have a vaginal delivery at any given time compared to their non-diabetic counterparts. In order to customize and individualize intrapartum care, it is imperative to conduct further investigations that illustrate the influence of hyperglycemia in pregnancy on the duration of active labor and on the outcomes during childbirth. In subsequent studies, it will be determined whether the observed difference in the duration of active labor, as indicated in the current studies, remains consistent when employing new definitions of active labor and labor progression.Suspected fetal macrosomia is the main reason for elective CS among women with type I diabetes and needs to be addressed further.
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| 6. |
- Stålberg, Valerie, et al.
(författare)
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Study protocol for a modified antenatal care program for pregnant women with a low risk for adverse outcomes - a stepped wedge cluster non-inferiority randomized trial
- 2022
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Ingår i: BMC Pregnancy and Childbirth. - London, United Kingdom : BioMed Central. - 1471-2393 .- 1471-2393. ; 22:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: It is crucial to provide care based on individual needs. Swedish health care is obliged to give care on equal conditions for the entire population. The person with the greatest need should be given the most care, and the health care system should strive to be cost-efficient. Medical and technical advances have been significant during the last decades and the recent Covid-19 pandemic has caused a shift in health care, from in-person visits to virtual visits. The majority of pregnant women with a low risk assessment have an uncomplicated antenatal course without adverse events. These women probably receive excessive and unnecessary antenatal care. This study will investigate if an antenatal care program for healthy pregnant women with a low risk for adverse outcomes could be safely monitored with fewer in-person visits to a midwife, and with some of them replaced by virtual visits.Methods: This is a non-inferiority trial where a stepped wedge cluster randomized controlled design will be used. Data collection includes register data and questionnaires that concern antenatal, obstetric and neonatal outcomes, patient- and caregiver-reported experiences, healthcare-economy, and implementation aspects. The modified antenatal care (MAC) study is performed in parts of the southeast of Sweden, which has approximately 8200 childbirths annually. At the start of the study, all antenatal care centers included in the study will use the same standard antenatal care (SAC) program. In the MAC program the in-person visits to a midwife will be reduced to four instead of eight, with two additional virtual meetings compared with the SAC program.Discussion: This presented study protocol is informed by research knowledge. The protocol is expected to provide a good structure for future studies on changed antenatal care programs that introduce virtual visits for healthy pregnant women with a low risk for adverse outcomes, without risking quality, safety, and increased costs.
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| 7. |
- Wolgast, Emelie, 1982-
(författare)
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Drug use during pregnancy with focus on antidepressants
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: More than half of pregnant women use at least one prescribed medication during pregnancy, and almost all pregnant women use some kind of over-the-counter medication. Depression is one of the most common diseases in the world today, also during the peripartum period. The prevalence of pregnant women using antidepressant medication is increasing. General knowledge about the use of medication during pregnancy needs to improve. The overall aim of the studies on which this thesis is based is therefore to examine different aspects of medication use during pregnancy, with a focus on antidepressants.Material and methods: Study I was a questionnaire study where 850 pregnant women were asked about their perceptions on medication use during pregnancy. In Study II, plasma samples from 200 women were obtained at gestational weeks 10-12 and 25, and screened for drugs. The results of the analysis were compared with medication use noted in antenatal medical care records. Study III was a national register‐based cohort study including 262,329 pregnant women, and their first child born in 2012-2015. Maternal obstetric and neonatal outcomes were studied in three groups: women diagnosed with depression and who had redeemed an antidepressant before becoming pregnant and women who were diagnosed with depression and who had redeemed an antidepressant both before and during pregnancy, were compared with each other and with women who had neither been diagnosed with depression nor been prescribed antidepressants. Study IV was a pharmacokinetic study that included 81 pregnant women with ongoing antidepressant medical treatment. Antidepressant drug and metabolite concentrations were measured throughout pregnancy. Participants were genotyped for enzymes involved in antidepressant drug metabolism, i.e. CYP2D6 and CYP2C19. Results and conclusions: The majority of pregnant women in our study considered the use of medication during pregnancy as either “probably harmful” or “harmful”, and this perception was associated with non-use of medication. The women had high confidence in health care professionals when seeking advice about medication.There was a good coherence between reported drug intake in antenatal care records and presence of the drug in the pregnant women’s blood. For drugs prescribed for continuous use the coherence was 100%; thus, the reported use of medication in antenatal records is reliable. Women with major depressive disorder and antidepressant medication prior to becoming pregnant were at increased risk for adverse obstetric and neonatal outcomes compared with women without major depressive disorder. Continuation of antidepressant medication during pregnancy somewhat increased the risk of adverse obstetric and neonatal outcomes. The dose-adjusted concentrations of sertraline and citalopram and their metabolites, did not change significantly throughout pregnancy. Observed concentrations of escitalopram, mirtazapine and venlafaxine did not appear to change.
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