| 1. |
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| 2. |
- Fellman, Vineta, et al.
(författare)
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One-year survival of extremely preterm infants after active perinatal care in Sweden.
- 2009
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Ingår i: JAMA : the journal of the American Medical Association. - : American Medical Association (AMA). - 1538-3598 .- 0098-7484. ; 301:21, s. 2225-33
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Tidskriftsartikel (refereegranskat)abstract
- Up-to-date information on infant survival after extremely preterm birth is needed for assessing perinatal care services, clinical guidelines, and parental counseling.
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| 3. |
- Jonsson, Maria, et al.
(författare)
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Acidemia at birth, related to obstetric characteristics and to oxytocin use, during the last two hours of labor
- 2008
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Ingår i: Acta Obstetricia et Gynecologica Scandinavica. - : Informa Healthcare. - 0001-6349 .- 1600-0412. ; 87:7, s. 745-750
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Tidskriftsartikel (refereegranskat)abstract
- Objective. Evaluate obstetric characteristics during the last two hours of labor in neonates born with acidemia. Design. Case-control study. Setting. Delivery units at two university hospitals in Sweden. Study population. Out of 28,486 deliveries during 1994-2004, 305 neonates had an umbilical artery pH value <7.05 at birth. Methods. Cases: neonates with an umbilical artery pH < 7.05. Controls were neonates with pH ≥ 7.05 and an Apgar score ≥7 at 5 minutes. Obstetric characteristics, cardiotocographic patterns and oxytocin treatment during the last two hours of labor were recorded. Results. In the univariate analysis, ≥6 contractions/10 minutes (odds ratio (OR) 4.94, 95% confidence interval (CI) 3.25-7.49), oxytocin use (OR 2.20, 95% CI 1.66-2.92), bearing down ≥45 minutes (OR 1.77, 95% CI 1.31-2.38) and occipito-posterior position (OR 2.18, 95% CI 1.19-3.98) were associated with acidemia at birth. In the multivariate analysis, only ≥6 contractions/10 minutes (OR 5.36, 95% CI 3.32-8.65) and oxytocin use (OR 1.89, 95% CI 1.21-2.97) were associated with acidemia at birth. Among cases with ≥6 contractions/10 minutes, 75% had been treated with oxytocin. Pathological cardiotocographic patterns occurred in 68.8% of cases and in 26.1% of controls (p<0.001). Conclusion. A hyperactive uterine contraction pattern and oxytocin use are the most important risk factors for acidemia at birth. The increased uterine activity was related to overstimulation in the majority of cases. The duration of bearing down is less important when uterine contraction frequency has been considered.
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| 4. |
- Jonsson, Maria, et al.
(författare)
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Analysis of malpractice claims with a focus on oxytocin use in labour
- 2007
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Ingår i: Acta Obstetricia et Gynecologica Scandinavica. - : Wiley. - 0001-6349 .- 1600-0412. ; 86:3, s. 315-319
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: The objective of this study was to analyse the motives behind disciplinary action in obstetric malpractice cases concerning delivery, and to evaluate the frequency of inappropriate oxytocin use in these cases. METHODS: An analysis of all malpractice claims resulting in disciplinary action against physicians and midwives during the period 1996-2003. Investigations and decisions made by the Board of Medical Responsibility were reviewed with special focus on the use of oxytocin. RESULTS: Of 77 cases, 60 regarded patients in labour. In the majority, there had been a normal pregnancy and spontaneous start of labour (78%). At the beginning of labour, 87% showed a normal fetal heart rate (FHR) pattern, indicating fetal well-being. In 70%, there was adverse fetal outcome with brain damage or death. The most common reason for disciplinary action was improper interpretation of fetal monitor tracings and corresponding failure to recognise fetal distress (76%). Injudicious use of oxytocin was common (68.5%), and was the primary reason for disciplinary action in 33% of the cases. CONCLUSION: In a Swedish setting, a few common clinical problems pervade; interpretation of FHR patterns and the use of oxytocin account for the majority of rulings of negligence in malpractice cases regarding delivery. Analysis of the cases suggests that the adverse fetal outcomes could possibly have been prevented.
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| 5. |
- Jonsson, Maria, 1966-, et al.
(författare)
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Metabolic acidosis at birth and suboptimal care - illustration of the gap between knowledge and clinical practice
- 2009
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Ingår i: BJOG: an international journal of obstetrics and gynaecology. - : Wiley. - 1470-0328. ; 116:11, s. 1453-1460
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Tidskriftsartikel (refereegranskat)abstract
- Objective To evaluate the occurrence and nature of suboptimal intrapartum care in cases with metabolic acidosis in the newborn, and to estimate the degree to which this may be prevented. Design Case-control study. Clinical audit. Setting Delivery units at two university hospitals in Sweden. Population Out of 28 486 deliveries, 161 neonates >= 34 weeks of gestational age were born with metabolic acidosis. Methods Cases (n = 161): umbilical artery pH < 7.05 and base deficit >= 12 mmol/l. Controls (n = 322): pH >= 7.05 and Apgar score >= 7 at 5 minutes. Obstetric characteristics and oxytocin administration were recorded. The last 2 hours of electronic fetal monitoring before delivery were evaluated blinded to outcome. Intrapartum management was analysed for suboptimal care by using predefined criteria. Main outcome measure Suboptimal intrapartum care. Results Case and control comparisons displayed an occurrence of suboptimal care in 49.1% versus 13.0% (P < 0.001), oxytocin misuse in 46.6% versus 13.0% (P < 0.001), a failure to respond to a pathological cardiotocographic pattern in 19.9% versus 1.2% (P < 0.001) and suboptimal care related to vacuum deliveries in 3.1% versus 0.3% (P < 0.01) respectively. Conclusion Metabolic acidosis at birth is often associated with suboptimal intrapartum care. The high rate of suboptimal care with regard to oxytocin use and fetal surveillance illustrate a gap between guidelines and clinical practice. Metabolic acidosis and related neonatal morbidity could potentially be prevented in 40-50% of cases. The adherence to guidelines must be checked.
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| 6. |
- Jonsson, Maria, 1966-
(författare)
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Use and Misuse of Oxytocin During Delivery
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Obstetric malpractice claims, concerning delivery during a period of eight years, were analysed for motives behind disciplinary actions, and for the frequency of inappropriate oxytocin use.Failure to respond to signs of foetal distress, injudicious use of oxytocin and a failure to effect a timely delivery were the recurrent problems that accounted for the majority of disciplinary actions. Inappropriate use of oxytocin was more frequent than reported in earlier studies. (Paper I) In a case-control study, differences in the obstetric management in neonates born with and without acidaemia (umbilical artery pH < 7.05), was evaluated. Out of 28,486 deliveries during 1994–2004, 305 neonates were born with acidaemia. Uterine hyperactivity and oxytocin use were independently associated to acidaemia at birth. The increased uterine activity was related to oxytocin treatment in 75 % of cases. Pathological cardiotocographic patterns occurred significantly more often in the case group. The results indicate that guidelines on oxytocin use and foetal surveillance are not followed. The duration of bearing down is less important when uterine contraction frequency has been considered. (Paper II) In a subset of study II, cases with metabolic acidosis (umbilical artery pH < 7.05 and base deficit ≥12 mmol/L) and controls were audited for the occurrence of suboptimal intrapartum care, and the nature of such care. It was found that suboptimal care occurred in half (49%) of the cases, while it was less frequent but not uncommon among controls (13%). Suboptimal care consisted of injudicious use of oxytocin and a failure of appropriate action upon signs of foetal distress. A high rate of NICU admissions and diagnosis of encephalopathy in the case group confirms that metabolic acidosis should be avoided. We estimate that metabolic acidosis could probably have been prevented in 40-50% of the cases.(PaperIII) Women (n=103) scheduled for elective caesarean section in regional anaesthesia were randomised to 5 or 10 units oxytocin, given as an intravenous bolus (double blinded), and electrocardiograms were analysed for ST depressions as a sign of myocardial ischaemia. ST depressions were associated with oxytocin administration significantly more often in subjects receiving 10 compared with 5 units. A dose of 10 units resulted in a more marked decrease of the mean arterial blood pressure, but no difference in increase of the heartrate. There was no difference in estimated blood loss. (paper IV)
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| 7. |
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| 8. |
- Wikström, Anna-Karin, 1965-
(författare)
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Biochemical and Epidemiological Studies of Early-Onset and Late-Onset Pre-Eclampsia
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Biochemical and epidemiological aspects of pre-eclampsia were investigated, with the main focus on possible pathophysiological differences between early-onset and late-onset disease.In pre-eclamptic women poor correlation was found between albumin-creatinine ratio (ACR) in a random urine sample and total amount of albumin in a 24-hour urine collection. (Paper I) In a cohort of women giving birth in Sweden in 1973-82 we estimated the adjusted incidence rate ratio (IRR) for ischaemic heart disease (IHD) during the years 1987–2001. The adjusted IRR for development of IHD was 1.6-2.8 in woman exposed to gestational hypertensive disease during her pregnancy compared with unexposed women. The higher risk represents more severe or recurrent hypertensive disease. (Paper II)Before delivery, in early-onset pre-eclampsia (24-32 weeks) there were pronounced alterations in plasma concentrations of soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PlGF), and also a higher placental 8-iso-PGF2α concentration and an elevated serum ratio of plasminogen-activator inhibitor (PAI)-1 to PAI-2 compared with early controls. In late-onset pre-eclampsia (35-42 weeks) there were only moderate alterations in sFlt1 and PlGF concentrations, and the placental 8-iso-PGF2α concentration and PAI-1/ PAI-2 ratio were similar to those in late controls. (Papers III, V) There was a rapid postpartum decrease in sFlt1 concentration in all groups. One week postpartum the sFlt1 concentration was persistently higher, however, in women with early-onset pre-eclampsia compared with early controls. (Paper IV)In conclusion: random ACR cannot replace 24-hour urine collections for quantification of albuminuria in pre-eclamptic women; gestational hypertensive disease, especially severe or recurrent, increases the risk for later IHD; early-onset, but not late-onset pre-eclampsia is associated with pronounced alterations of angiogenesis-related markers and only early-onset pre-eclampsia is associated with placental oxidative stress and an increased PAI-1/ PAI-2 ratio, all suggesting a stronger link between early-onset than late-onset pre-eclampsia and a dysfunctional placenta.
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| 9. |
- Wikström, Anna-Karin, et al.
(författare)
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Placental growth factor and soluble fms-like tyrosine kinase-1 in early-onset and late-onset preeclampsia
- 2007
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Ingår i: Obstetrics and Gynecology. - 0029-7844 .- 1873-233X. ; 109:6, s. 1368-1374
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To estimate whether alterations in plasma levels of the proangiogenic proteins placental growth factor (PlGF) and vascular endothelial growth factor-A (VEGF-A), and the antiangiogenic protein soluble fms-like tyrosine kinase-1 (sFlt1) were more pronounced in early-onset than in late-onset preeclampsia. METHODS: A cross-sectional study was conducted to estimate the levels of sFlt1, PlGF, and VEGF-A in plasma in a control group of nonpregnant women, in an early control group of women at 24-32 weeks of gestation, in a late control group of women at 36-42 weeks of gestation, and in cases of women with early-onset (before 32 weeks of gestation) and late-onset (after 35 weeks of gestation) preeclampsia. RESULTS: Women with early-onset preeclampsia had a 43 times higher median plasma sFlt1 level than early controls (P<.001). Women with late-onset preeclampsia had a three times higher median plasma sFlt1 level than late controls (P<.001). Women with early-onset preeclampsia had a 21 times lower median plasma PlGF level than early controls (P<.001). Women with late-onset preeclampsia had a five times lower median plasma PlGF level than late controls (P=.01). The median level of VEGF-A in plasma was less than 15 pg/mL in all groups of pregnant women. CONCLUSION: Both early- and late-onset preeclampsia are associated with altered plasma levels of sFlt1 and PlGF. The alterations are more pronounced in early-onset rather than in late-onset disease.
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| 10. |
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| 11. |
- Zetterström, Karin, et al.
(författare)
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Chronic hypertension as a risk factor for offspring to be born small for gestational age
- 2006
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Ingår i: Acta Obstetricia et Gynecologica Scandinavica. - : Wiley. - 0001-6349 .- 1600-0412. ; 85:9, s. 1046-1050
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Tidskriftsartikel (refereegranskat)abstract
- Background. Chronic hypertension during pregnancy is associated with an increased risk for birth of small for gestational age offspring. The aim of this study was to determine whether the risk remains after consideration of maternal characteristics and superimposed pre-eclampsia. Method. A population-based cohort study based on the Swedish Medical Birth Register 1992-98 and comprising 560,188 women aged 15-44 years with singleton pregnancies including 2,754 women with chronic hypertension. The register contains data of maternal characteristics besides maternal and fetal complications. Multiple logistic regression analysis was used. Small for gestational age was defined as birth weight less than -2SD adjusted for gestational age and sex. Results. Chronic hypertensive women have an independent risk for small for gestational age (OR 3.1; 95% CI 2.7-3.7) when controlling for confounding of maternal characteristics such as age, parity, BMI, smoking, and ethnical origin. After introducing superimposed pre-eclampsia in the model the risk remains but decreases (OR 2.4; 95% CI 2.1-2.9). Conclusion. Chronic hypertension is an independent risk factor for birth of small for gestational age offspring. Pre-eclampsia is a strong mediating factor.
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| 12. |
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| 13. |
- Zetterström, Karin, et al.
(författare)
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The association of maternal chronic hypertension with perinatal death in male and female offspring : a record linkage study of 866,188 women
- 2008
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Ingår i: British Journal of Obstetrics and Gynecology. - Oxford : Wiley-Blackwell Publishing Inc.. - 1470-0328 .- 1471-0528. ; 115:11, s. 1436-1442
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Tidskriftsartikel (refereegranskat)abstract
- Objective The purpose of this study was to determine whether there is a difference, by gender, in perinatal mortality in chronically hypertensive women compared with normotensive women. Design Population-based prospective cohort study. Setting Sweden. Population A total of 866 188 women with singleton pregnancies registered in the Swedish Medical Birth Registry 1992–2004, of which 4749 were diagnosed with chronic hypertension. Methods Multivariate logistic regression analysis was performed. In a first step, we adjusted for maternal characteristics and in a second step for mild and severe pre-eclampsia, gestational diabetes, placental abruption and small for gestational age. An effect modification by gender was included in the model. Main outcome measures Odds ratios (OR) for intrauterine death, neonatal death and post-neonatal death with respect to gender of offspring. Results The unadjusted OR of intrauterine death was 4.12 (95% CI: 2.84–5.96) and 1.29 (95% CI: 0.67–2.48) for male and female offspring, respectively, and of neonatal death, it was 3.45 (95% CI: 2.13–5.59) and 2.17 (95% CI: 1.08–4.35) for male and female offspring, respectively. After multivariate analysis, the OR of intrauterine death was 3.07 (95% CI: 2.12–4.46) and neonatal death was 2.99 (95% CI: 1.84–4.85) for male offspring. For female offspring, the OR of intrauterine death was 0.98 (95% CI: 0.51–1.89) and neonatal death was 1.88 (95% CI: 0.93–3.79). Conclusion Mothers with chronic hypertension have an increased risk of perinatal mortality of their male offspring.
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