| 1. |
- Belachew, Johanna, 1976-
(författare)
-
Retained Placenta and Postpartum Haemorrhage
- 2015
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim was to explore the possibility to diagnose retained placental tissue and other placental complications with 3D ultrasound and to investigate the impact of previous caesarean section on placentation in forthcoming pregnancies.3D ultrasound was used to measure the volumes of the uterine body and cavity in 50 women with uncomplicated deliveries throughout the postpartum period. These volumes were then used as reference, to diagnose retained placental tissue in 25 women with secondary postpartum haemorrhage. All but three of the 25 women had retained placental tissue confirmed at histopathology. The volume of the uterine cavity in women with retained placental tissue was larger than the reference in most cases, but even cavities with no retained placental tissue were enlarged (Studies I and II).Women with their first and second birth, recorded in the Swedish medical birth register, were studied in order to find an association between previous caesarean section and retained placenta. The risk of retained placenta with heavy bleeding (>1,000 mL) and normal bleeding (≤1,000 mL) was estimated for 19,459 women with first caesarean section delivery, using 239,150 women with first vaginal delivery as controls. There was an increased risk of retained placenta with heavy bleeding in women with previous caesarean section (adjusted OR 1.61; 95% CI 1.44-1.79). There was no increased risk of retained placenta with normal bleeding (Study III).Placental location, myometrial thickness and Vascularisation Index were recorded on 400 women previously delivered by caesarean section. The outcome was retained placenta and postpartum haemorrhage (≥1,000 mL). There was a trend towards increased risk of postpartum haemorrhage for women with anterior placentae. Women with placenta praevia had an increased risk of retained placenta and postpartum haemorrhage. Vascularisation Index and myometrial thickness did not associate (Study IV).In conclusion: 3D ultrasound can be used to measure the volume of the uterine body and cavity postpartum, but does not increase the diagnostic accuracy of retained placental tissue. Previous caesarean section increases the risk of retained placenta in subsequent pregnancy, and placenta praevia in women with previous caesarean section increases the risk for retained placenta and postpartum haemorrhage.
|
|
| 2. |
- Huber, Malin, 1979-
(författare)
-
To tear and to heal : pelvic floor dysfunction and childbirth
- 2023
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Up to 80% of women are affected by a perineal laceration after their first vaginal birth. An estimated 40–50% of lacerations involve the perineal muscles, and up to 7% are obstetric anal sphincter injuries (OASI). There is a lack of knowledge about the extent of short-term complications such as pelvic floor dysfunction (PFD) following spontaneous or iatrogenic pelvic floor trauma. Women’s experiences of daily life after childbirth complicated by OASI is poorly understood. Three-dimensional endoanal ultrasonography (3D-EAUS) is a welldocumented method for evaluating damage to the anal sphincter in other contexts. Adding ultrasonography to standard clinical examination has revealed injuries previously missed, and research evaluating diagnostic methods for the routine screening of OASI has been called for.Aim: This thesis aims to evaluate the diagnostics of OASI, determine if the degree of perineal injury or anal sphincter defects after childbirth are associated with pelvic dysfunction, and explore women’s experiences of OASI.Methods Studies I and IV were prospective cohort-studies to evaluate any association between perineal tear or sphincter defect to PFD. Study II was an interview study addressing women’s experiences of OASI by qualitative content analysis. Study III was a cross-sectional study designed to examine the utility of endoanal ultrasound to detect OASI. Participants were clinically examined after birth and 3D-EAUS was performed immediately after giving birth and 3 months postpartum. PFD was evaluated using a web-based questionnaire one year after delivery.Results: A total of 511 women completed the one-year questionnaire (Study I) and a purposive sample of 11 women were invited to take part in Study II. In Study III, 680 women underwent a clinical examination and 3D-EAUS recording immediately after birth. In Study IV, 239 women who attended all follow-ups were included. PFD was experienced by women with a perineal laceration of any grade, but also those with an intact perineum. Dyspareunia and urinary incontinence were the most common problems. Women with OASI had a higher risk for developing vi symptoms of prolapse, urinary urge incontinence, dyspareunia, and pain as well as experiencing a negative impact on their daily life. Elements that negatively influenced women’s experiences of OASI were pain and symptoms of PFD, normalisation of symptoms by healthcare providers, and unrealistic expectations about this period in life. 3D-EAUS immediately after delivery had poor sensitivity and specificity in detecting clinically diagnosed OASI. Postpartum anal sphincter defects were associated with genital pain and dyspareunia.Conclusions: OASI is an evident risk factor for pelvic floor dysfunction after childbirth, but symptoms of pelvic floor disorder were found to be common, even in women with mild to moderate perineal laceration. OASI has a negative impact on how a woman experiences relationships, social contact, and sexuality. Using 3D-EAUS in a maternity ward to diagnose OASI is demanding. Staff generally have little experience in 3D-EAUS. There are also difficulties in obtaining good image quality, due to local oedema, bleeding, positioning of the woman, and unintentional movements. These factors all complicate the interpretation of images.
|
|
| 3. |
- Kahrs, Birgitte H., et al.
(författare)
-
Fetal rotation during vacuum extractions for prolonged labor : a prospective cohort study
- 2018
-
Ingår i: Acta Obstetricia et Gynecologica Scandinavica. - : Wiley. - 0001-6349. ; 97:8, s. 998-1005
-
Tidskriftsartikel (refereegranskat)abstract
- Introduction: The aim of the study was to investigate fetal head rotation during vacuum extraction. Material and methods: We conducted a prospective cohort study from November 2013 to July 2016 in seven European hospitals. Fetal head position was determined with transabdominal or transperineal ultrasound and categorized as occiput anterior (OA), occiput transverse (OT) or occiput posterior (OP) position. Main outcome was the proportion of fetuses rotating during vacuum extraction. Secondary outcomes were conversion of delivery method, duration of vacuum extraction, umbilical artery pH <7.10 and agreement between clinical and ultrasound assessments. Results: The study population comprised 165 women. During vacuum extraction 117/119 (98%) remained in OA and two fetuses rotated to OP position. Rotation from OT to OA position occurred in 14/19 (74%) and to OP position in 5/19 (26%). Rotation from OP to OA position occurred in 15/25 (60%), and 10/25 (40%) fetuses remained in OP position. Delivery information was missing in two cases. The conversion rate from vacuum extraction to cesarean section or forceps was 10% in the OA group vs. 23% in the non-OA group; p < 0.05. The estimated duration of vacuum extraction was significantly shorter in OA fetuses, 7 min vs. 10 min (log rank test p < 0.01). There was no significant difference in umbilical artery pH < 7.10 between OA and non-OA position. Cohens Kappa of agreement between clinical and ultrasound assessments was 0.42 (95% CI 0.26–0.57). Conclusion: Most fetuses in OP or OT positions rotated to OA position during vacuum extraction, but the proportion of failed vacuum extractions remained high.
|
|
| 4. |
- Lindström, Linda, 1978-
(författare)
-
Born Small for Gestational Age : Beyond Size at Birth
- 2019
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Children born small for gestational age (SGA) run increased risk of perinatal morbidity and mortality, but also of long-term health impairment. Risks on long term may vary depending on postnatal growth patterns. The overall aim of the thesis was to gain further knowledge about long-term consequences of being born SGA, as well as the impact of perinatal exposures on postnatal growth patterns. The thesis is based on four register-based cohort studies.In paper I, risk of chronic hypertension was assessed in 731,008 first-time mothers. Perinatal exposure to pre-eclampsia, being born SGA and preterm were all independently associated with increased risk of chronic hypertension. The risk was further enhanced after combined exposure. The strongest association was seen in combinations including pre-eclampsia.In paper II, risk of poor school performance at time of graduation from compulsory school was assessed in 1,088,980 children born SGA at term. Being born SGA was associated with increased risk of poor school performance, following a dose-response pattern with increased risk even for birthweight for gestational age (GA) –1.01 to –2 SD. Boys with short adult stature were associated with higher risk of poor school performance than those with non-short stature.In paper III, differences in postnatal growth patterns depending on SGA status and maternal smoking habits were assessed in 32,493 children. Children born SGA with smoking mothers had a more rapid catch-up growth than those with non-smoking mothers. Compared with children born appropriate for GA (AGA) with non-smoking mothers, only children born SGA with non-smoking mothers were associated with increased risk of short stature at 1.5 and 5 years.In paper IV, differences in postnatal growth patterns until age five years, depending on SGA status and GA at birth, were assessed in 41,669 children born between 32-40 gestational weeks. Being born SGA and moderate to late preterm was associated with shorter stature and lower BMI, compared with being born AGA at term. SGA status had greater impact on growth and body proportions than GA at birth.In conclusion, children born SGA are at higher risk of chronic hypertension and cognitive impairment than children born AGA. Postnatal growth patterns vary in children born SGA, depending on intrauterine exposure to smoking and GA at birth. This may modify risks of long-term health impairment.
|
|
| 5. |
- Rogozińska, Ewelina, et al.
(författare)
-
Effects of antenatal diet and physical activity on maternal and fetal outcomes : Individual patient data meta-analysis and health economic evaluation
- 2017
-
Ingår i: Health Technology Assessment. - : National Institute for Health Research. - 1366-5278 .- 2046-4924. ; 21:41
-
Tidskriftsartikel (refereegranskat)abstract
- Background: Diet- and physical activity-based interventions in pregnancy have the potential to alter maternal and child outcomes. Objectives: To assess whether or not the effects of diet and lifestyle interventions vary in subgroups of women, based on maternal body mass index (BMI), age, parity, Caucasian ethnicity and underlying medical condition(s), by undertaking an individual patient data (IPD) meta-analysis. We also evaluated the association of gestational weight gain (GWG) with adverse pregnancy outcomes and assessed the cost-effectiveness of the interventions. Data sources: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment database were searched from October 2013 to March 2015 (to update a previous search). Review methods: Researchers from the International Weight Management in Pregnancy Collaborative Network shared the primary data. For each intervention type and outcome, we performed a two-step IPD random-effects meta-analysis, for all women (except underweight) combined and for each subgroup of interest, to obtain summary estimates of effects and 95% confidence intervals (CIs), and synthesised the differences in effects between subgroups. In the first stage, we fitted a linear regression adjusted for baseline (for continuous outcomes) or a logistic regression model (for binary outcomes) in each study separately; estimates were combined across studies using random-effects meta-analysis models. We quantified the relationship between weight gain and complications, and undertook a decision-analytic model-based economic evaluation to assess the cost-effectiveness of the interventions. Results: Diet and lifestyle interventions reduced GWG by an average of 0.70 kg (95% CI-0.92 to-0.48 kg; 33 studies, 9320 women). The effects on composite maternal outcome [summary odds ratio (OR) 0.90, 95% CI 0.79 to 1.03; 24 studies, 8852 women] and composite fetal/neonatal outcome (summary OR 0.94, 95% CI 0.83 to 1.08; 18 studies, 7981 women) were not significant. The effect did not vary with baseline BMI, age, ethnicity, parity or underlying medical conditions for GWG, and composite maternal and fetal outcomes. Lifestyle interventions reduce Caesarean sections (OR 0.91, 95% CI 0.83 to 0.99), but not other individual maternal outcomes such as gestational diabetes mellitus (OR 0.89, 95% CI 0.72 to 1.10), pre-eclampsia or pregnancy-induced hypertension (OR 0.95, 95% CI 0.78 to 1.16) and preterm birth (OR 0.94, 95% CI 0.78 to 1.13). There was no significant effect on fetal outcomes. The interventions were not cost-effective. GWG, including adherence to the Institute of Medicine-recommended targets, was not associated with a reduction in complications. Predictors of GWG were maternal age (summary estimate-0.10 kg, 95% CI-0.14 to-0.06 kg) and multiparity (summary estimate-0.73 kg, 95% CI-1.24 to-0.23 kg). Limitations: The findings were limited by the lack of standardisation in the components of intervention, residual heterogeneity in effects across studies for most analyses and the unavailability of IPD in some studies. Conclusion: Diet and lifestyle interventions in pregnancy are clinically effective in reducing GWG irrespective of risk factors, with no effects on composite maternal and fetal outcomes. Future work: The differential effects of lifestyle interventions on individual pregnancy outcomes need evaluation. Study registration: This study is registered as PROSPERO CRD42013003804.
|
|
