Maternal outcome after complete uterine rupture

Introduction: Complete uterine rupture, a rare peripartum complication, is often associated with a catastrophic outcome for both mother and child. However, few studies have investigated large datasets to evaluate maternal outcomes after complete ruptures, particularly in unscarred uteri. This paucity of studies is partly due to the rarity of both the event and the serious outcomes, such as peripartum hysterectomy and maternal death. The incidence of uterine rupture is expected to increase, due to increasing cesarean section rates worldwide. Thus, it is important to have more complete knowledge about the immediate maternal outcome following a complete uterine rupture. The objective was to identify maternal outcomes and their risk factors following complete uterine ruptures. Material and methods: This was a population‐based study using data from the Medical Birth Registry of Norway, the Patient Administration System and medical records. Maternities with complete uterine rupture after start of labor in Norway during 1967‐2008 (n = 247 births), identified among 2 209 506 women. Uterine ruptures were identified from both registries and were further studied through a review of medical records. Only complete ruptures were included in analysis. The associations between maternal outcomes and demographic and labor risk factors were estimated. Odds ratios (OR s) were determined with crude logistic regressions for each risk factor. Separate multivariable logistic regressions were performed to calculate adjusted odds ratios and 95% confidence intervals (CI s). Results: We identified 88 (35.6%) healthy mothers, 107 (43.3%) severe postpartum hemorrhages without hysterectomy, 51 (20.6%) peripartum hysterectomies, and three (1.2%) maternal deaths. Peripartum hysterectomy decreased significantly in the last years of study. Unscarred uterine ruptures significantly increased the risk of peripartum hysterectomy compared with scarred uterine ruptures (AOR 2.6, 95% CI 1.3‐5.3). Other factors that increased the risk of peripartum hysterectomy following rupture were: maternal age ≥35 years (AOR 2.3, 95% CI 1.1‐5.0), parity ≥3 vs parity 1‐2 (AOR 2.8, 95% CI 1.2‐6.7), and rupture detection after vaginal delivery (AOR 2.2, 95% CI 1.1‐4.8). Conclusions: Unscarred uteri, older maternal age, parity ≥3, and rupture detection after vaginal delivery showed the highest associations with the risk of peripartum hysterectomy after complete uterine rupture.acceptedVersio

Factors Associated with Prenatal Folic Acid and Iron Supplementation Among 21,889 Pregnant women in Northern Tanzania: A Cross-Sectional Hospital-Based Study.

Folate and iron deficiency during pregnancy are risk factors for anaemia, preterm delivery, and low birth weight, and may contribute to poor neonatal health and increased maternal mortality. The World Health Organization recommends supplementation of folic acid (FA) and iron for all pregnant women at risk of malnutrition to prevent anaemia. We assessed the use of prenatal folic acid and iron supplementation among women in a geographical area with a high prevalence of anaemia, in relation to socio-demographic, morbidity and health services utilization factors. We analysed a cohort of 21,889 women who delivered at Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania, between 1999 and 2008. Logistic regression models were used to describe patterns of reported intake of prenatal FA and iron supplements. Prenatal intake of FA and iron supplements was reported by 17.2% and 22.3% of pregnant women, respectively. Sixteen percent of women reported intake of both FA and iron. Factors positively associated with FA supplementation were advanced maternal age (OR = 1.17, 1.02-1.34), unknown HIV status (OR = 1.54, 1.42-1.67), a diagnosis of anaemia during pregnancy (OR = 12.03, 9.66-14.98) and indicators of lower socioeconomic status. Women were less likely to take these supplements if they reported having had a malaria episode before (OR = 0.57, 0.53-0.62) or during pregnancy (OR = 0.45, 0.41-0.51), reported having contracted other infectious diseases (OR = 0.45, 0.42-0.49), were multiparous (OR = 0.73, 0.66-0.80), had preeclampsia/eclampsia (OR = 0.48, 0.38-0.61), or other diseases (OR = 0.55, 0.44-0.69) during pregnancy. Similar patterns of association emerged when iron supplementation alone and supplementation with both iron and FA were evaluated. FA and iron supplementation are low among pregnant women in Northern Tanzania, in particular among women with co-morbidities before or during pregnancy. Attempts should be made to increase supplementation both in general and among women with pregnancy complications

Exposure to breastfeeding and risk of developing multiple sclerosis

Background: Early-life factors are reported to modulate the risk of developing multiple sclerosis (MS) among adults. The association between exposure to breastfeeding and the risk of MS is debated. We aimed to disclose whether past exposure to breastfeeding and its duration are associated with the risk of developing MS. Methods: We used a cohort design linking prospectively collected information on breastfeeding from the Cohort of Norway community-based surveys on health status (CONOR) with the Norwegian MS Registry and the population-based Medical Birth Registry of Norway that includes information on all births in Norway since 1967. MS clinical onset was collected throughout 2016. A total of 95 891 offspring born between 1922 and 1986 to mothers participating in CONOR were included. We identified 215 offspring within this cohort who developed adult-onset MS. Associations between breastfeeding and MS risk were estimated as hazard ratios using Cox proportional hazard models adjusting for maternal factors including education. Results: We found no association between having been breastfed for ≥4 months and MS risk, also after adjusting for various maternal factors (hazard ratio = 0.90; 95% confidence interval 0.68-1.19). The estimates did not change for different durations of breastfeeding. The results were similar when adjusting for other perinatal factors. Conclusion: Our study could not confirm previous findings of an association between breastfeeding and risk of MS. Breastfeeding information was less likely to be biased by knowledge of disease compared with case-control studies

Maternal antiretroviral treatment for HIV infection and risk of small-for-gestational-age birth: A systematic review and meta-analysis of protease inhibitor-based treatment and timing of treatment

Background Data indicate that certain combination antiretroviral treatment (cART) regimens, particularly protease inhibitor (PI)-based regimens, and cART initiation before conception may be associated with adverse pregnancy outcomes. The risk of having a small-for-gestational-age (SGA) infant was examined among pregnant HIV-infected mothers on 1) PI-based compared to non-PI-based cART, and 2) any cART initiated before compared to after conception. Methods A search was conducted using PubMed, Embase, and the Cochrane Library, and a systematic review was performed of studies published since Dec 1, 1995. Effect estimates with 95% confidence intervals (CIs) were extracted and meta-analyses with random-effects models were conducted. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. Findings Of 783 identified studies, 28 fulfilled the inclusion criteria. Meta-analysis indicated that PI-based cART was associated with a possible slightly increased risk of SGA compared with non-PI-based cART (pooled odds ratio [OR]: 1·09; CI: 0·76, 1·55). Initiation of cART before conception was also associated with a possible slightly increased risk of SGA compared with after conception (pooled OR: 1·08; CI: 0·95, 1·22). The overall certainty of evidence was very low and low for the first and second research questions, respectively. Interpretation Although the benefits of cART largely outweigh the risks, these findings indicate the possibility of slightly increased risks of having an SGA infant. This indicates that careful monitoring of fetuses exposed to PI-based cART or cART before pregnancy might be reasonable. Based on the uncertainty of evidence, further research may change this conclusion.publishedVersio

Psychiatric Comorbidity, Social Aspects and Quality of Life in a Population-Based Cohort of Expecting Fathers with Epilepsy

Objectives. To investigate psychiatric disorders, adverse social aspects and quality of life in men with epilepsy during partner’s pregnancy. Method. We used data from the Norwegian Mother and Child Cohort Study, including 76,335 men with pregnant partners. Men with epilepsy were compared to men without epilepsy, and to men with non-neurological chronic diseases. Results. Expecting fathers in 658 pregnancies (mean age 31.8 years) reported a history of epilepsy, 36.9% using antiepileptic drugs (AEDs) at the onset of pregnancy. Symptoms of anxiety or depression were increased in epilepsy (7.0% and 3.9%, respectively) vs. non-epilepsy (4.6% and 2.5%, respectively, p = 0.004 and 0.023), and so were new onset symptoms of depression (2.0% vs. 1.0%, p < 0.031) and anxiety (4.3% vs. 2.3%, p = 0.023). Low self-esteem (2.5%) and low satisfaction with life (1.7%) were more frequent among fathers with epilepsy compared to fathers without epilepsy (1.3% and 0.7%, respectively, p = 0.01 and 0.010). Adverse social aspects and life events were associated with epilepsy vs. both reference groups. Self-reported diagnoses of ADHD (2.2%) and bipolar disorder (1.8%) were more common in epilepsy vs. non-epilepsy (0.4% and 0.3%, respectively, p = 0.002 and 0.003) and non-neurological chronic disorders (0.5% and 0.5%, respectively, p = 0.004 and 0.018). A screening tool for ADHD symptoms revealed a higher rate compared to self-reported ADHD (9.5% vs. 2.2%, p < 0.001). Conclusion. Expecting fathers with epilepsy are at high risk of depression and anxiety, adverse socioeconomic aspects, low self-esteem, and low satisfaction with life. Focus on mental health in fathers with epilepsy during and after pregnancy is important. The use of screening tools can be particularly useful to identify those at risk.publishedVersio

Time trends in perinatal outcomes among HIV-positive pregnant women in Northern Tanzania: A registry-based study

Introduction Maternal HIV infection is associated with increased risk of having a preterm delivery, low birth weight baby, small for gestational age baby and stillbirth. Maternal use of combination antiretroviral treatment is also associated with preterm delivery and low birth weight, although the effects vary by the type of drugs and timing of initiation. Objective To examine time trends in adverse perinatal outcomes among HIV-positive compared with HIV-negative women. Design Registry-based cohort study. Setting Northern Tanzania, 2000–2018. Study sample Mother-baby pairs of singleton deliveries (n = 41 156). Methods Perinatal outcomes of HIV-positive women were compared with HIV-negative women during time periods representing shifts in prevention of mother-to-child transmission guidelines. Monotherapy was used as first-line therapy before 2007 while combination antiretroviral treatment was routinely used from 2007. Log binomial and quantile regression were used to analyze the data. Main outcome measures Preterm delivery, low birth weight, perinatal death, stillbirth, low Apgar score, transfer to neonatal care unit and small for gestational age. Results Overall, maternal HIV infection was associated with a higher risk of low birth weight and small for gestational age. Moreover, this pattern became more pronounced over time for low birth weight, the last time period being an exception. For other outcomes we found none or only a small overall association with maternal HIV infection, although a trend towards higher risk over time in HIV-positive compared with HIV-negative women was observed for preterm delivery and perinatal death. Quantile regression showed an increase in birth weight in babies born to HIV-negative women over time and a corresponding decline in birth weight in babies born to HIV-positive women. Conclusion Unfavourable trends in some of the selected perinatal outcomes were seen for HIV-positive compared with HIV-negative women. Potential side-effects of combination antiretroviral treatment in pregnancy should be further explored.publishedVersio

Kvinners erfaringer med abortnemnder

Denne rapporten presenterer resultatene fra en amfunnsvitenskapelig studie om kvinners erfaringer med abortnemnder. Rapporten bygger på 13 dybdeintervju med kvinner som hadde erfaring med å søke om og gjennomleve andretrimesterabort innenfor et abortnemndsystem. Kvinnene hadde fått sine abortbegjæringer behandlet i nemnd ved åtte ulike sykehus i hele landet. Studien undersøkte kvinnenes helhetlige prosess med å søke andretrimesterabort innen rammene av et abortnemndsystem, opplevelser knyttet til selve møtet med nemnden og kvinnenes erfaringer knyttet til nemndenes myndighet til å fatte beslutning om deres liv samtidig som de skal ivareta kvinnenes rett til informasjon og veiledning. Kvinnene fortalte sine historier fra de oppdaget svangerskapet til tiden etter at abortfødsel var overstått. Analysen som presenteres i denne rapporten fokuserer på temaene 1) Forventninger og forberedelser til nemndsmøtet, 2) Å møte abortnemnden og 3) Tidsrammer og oppfølging. Studien viser at tiden før selve nemndsmøtet preges av varierende forkunnskaper og ulik og mangelfull informasjon til kvinnene om plikter og rettigheter ved nemndsbehandling. Muligheten for å få avslag preget kvinnene i forkant av nemndsmøtet, og gjorde kvinnenes beslutningsprosess vanskeligere. Videre viser studien at abortnemndene organiseres svært ulikt fra sykehus til sykehus. Noen kvinner opplevde at nemnden ga råd og støtte utover det å avklare om aborten oppfylte lovens kriterier. Mens noen opplevde nemndsmøtet som både belastende og meningsløst, opplevde andre det som en støtte. Metaforer som «eksamen» eller «avhør» ble brukt til å beskrive noen av kvinnenes møte med nemnden. Kvinner som hadde søkt om å få avslutte et ønsket svangerskap var frustrert over at partner ikke hadde plass som part i nemndsystemet. Tidsaspektet formet kvinnenes opplevelser med nemndsbehandling. For noen var det å vente på nemnden en belastning. For andre gjorde lovens grenser for svangerskapets avslutning at vanskelige avgjørelser måtte tas på kort tid. Kvinnene hadde et stort behov for støtte og oppfølging etter abortfødsel, og i dag er det ikke noe system som sikrer dette. Abortnemndene utgjør bare én del av et større system som aktiveres når en kvinne søker en andretrimesterabort. Kvinnenes erfaringer med abortnemndsystemet preges av skjevheten i makt mellom dem selv og nemnden. Denne skjevheten begrenser rommet for tvil og muligheten for en god og opplysende dialog. Noen kvinner opplever at møtet med nemnd gir dem større kontroll over egen situasjon. Slik det fungerer i dag favoriserer nemndsystemet ressurssterke kvinner og kan bidra til å ytterligere marginalisere sårbare kvinner. Uklarhet og ulik praksis knyttet til abortnemndens oppgave utover det å fatte et vedtak om andretrimesterabort, skaper risiko for at viktig informasjon ikke formidles. Dette svekker kvinners rett til å ikke delta i nemndsmøte samt hennes mulighet til å handle på bakgrunn av riktig informasjon. Dagens system tar i liten grad høyde for at de fleste andrestrimesteraborter er avbrudd av ønskede svangerskap. For kvinner som opplever dette virker abortnemdsystemet fremmedgjørende og lite forståelsesfullt. Dette kan gjøre den vanskelige tiden etter en gjennomført abort ekstra krevende. Dagens helsesystem sikrer ikke god oppfølging til kvinnene som gjennomgår en andretrimesterabort. Tiden etter en gjennomført abortfødsel er den mest sårbare for kvinnene som har vært gjennom abortnemndsystemet. Det er grunn til å stille spørsmål til ressursbruken knyttet til nemndsmøtene i kontrast til få ressurser til oppfølgingstjenester

Heart failure in women with hypertensive disorders of pregnancy: Insights from the cardiovascular disease in Norway project

Hypertensive disorders of pregnancy (HDP) have been associated with heart failure (HF). It is unknown whether concurrent pregnancy complications (small-for-gestational-age or preterm delivery) or recurrent HDP modify HDP-associated HF risk. In this cohort study, we included Norwegian women with a first birth between 1980 and 2004. Follow-up occurred through 2009. Cox models examined gestational hypertension and preeclampsia in the first pregnancy as predictors of a composite of HF-related hospitalization or HF-related death, with assessment of effect modification by concurrent small-for-gestational-age or preterm delivery. Additional models were stratified by final parity (1 versus ≥2 births) and tested associations with recurrent HDP. Among 508 422 women, 565 experienced incident HF over a median 11.8 years of follow-up. After multivariable adjustment, gestational hypertension in the first birth was not significantly associated with HF (hazard ratio, 1.41 [95% CI, 0.84–2.35], P=0.19), whereas preeclampsia was associated with a hazard ratio of 2.00 (95% CI, 1.50–2.68, P<0.001). Among women with HDP, risks were not modified by concurrent small-for-gestational-age or preterm delivery (Pinteraction=0.42). Largest hazards of HF were observed in women whose only lifetime birth was complicated by preeclampsia and women with recurrent preeclampsia. HF risks were similar after excluding women with coronary artery disease. In summary, women with preeclampsia, especially those with one lifetime birth and those with recurrent preeclampsia, experienced increased HF risk compared to women without HDP. Further research is needed to clarify causal mechanisms.acceptedVersio

Prenatal exposure to pregabalin, birth outcomes and neurodevelopment - a population-based cohort study in four Nordic countries

Introduction: Pregabalin is an antiepileptic drug frequently prescribed to pregnant women. Risks of adverse birth and postnatal neurodevelopmental outcomes following prenatal exposure to pregabalin are uncertain. Objective: To investigate the association between prenatal exposure to pregabalin and the risks of adverse birth and postnatal neurodevelopmental outcomes. Methods: This study was conducted using population-based registries in Denmark, Finland, Norway, and Sweden (2005–2016). We compared pregabalin exposure against no exposure to antiepileptics and against active comparators lamotrigine and duloxetine. We obtained pooled propensity score-adjusted estimates of association using fixed-effect and Mantel–Haenszel (MH) meta-analyses. Results: The total number of pregabalin-exposed births was 325/666,139 (0.05%) in Denmark, 965/643,088 (0.15%) in Finland, 307/657,451 (0.05%) in Norway, and 1275/1,152,002 (0.11%) in Sweden. The adjusted prevalence ratios (aPRs) with 95% confidence interval (CI) following pregabalin exposure versus no exposure were 1.14 (0.98–1.34) for major congenital malformations and 1.72 (1.02–2.91) for stillbirth, which attenuated to 1.25 (0.74–2.11) in MH meta-analysis. For the remaining birth outcomes, the aPRs were close to or attenuated toward unity in analyses using active comparators. Adjusted hazard ratios (95% CI) contrasting prenatal pregabalin exposure versus no exposure were 1.29 (1.03–1.63) for ADHD and attenuated when using active comparators, 0.98 (0.67–1.42) for autism spectrum disorders, and 1.00 (0.78–1.29) for intellectual disability. Conclusions: Prenatal exposure to pregabalin was not associated with low birth weight, preterm birth, small for gestational age, low Apgar score, microcephaly, autism spectrum disorders, or intellectual disability. On the basis of the upper value of the 95% confidence interval, increased risks greater than 1.8 were unlikely for any major congenital malformation and ADHD. For stillbirth and most groups of specific major congenital malformations, the estimates attenuated in MH meta-analysis.publishedVersio

Association of adverse childhood experiences with the development of multiple sclerosis

Objective To study whether exposure to childhood emotional, sexual or physical abuse is associated with subsequent multiple sclerosis (MS) development. Methods A nationwide, prospective cohort study based on participants in the Norwegian Mother, Father and Child cohort study. Enrolment took place 1999–2008, with follow-up until 31 December 2018. Childhood abuse before age 18 years was obtained from self-completed questionnaires. We identified MS diagnoses through data-linkage with national health registries and hospital records. The Cox model was used to estimate HRs for MS with 95% CIs, adjusting for confounders and mediators. Results In this prospective cohort study, 14 477 women were exposed to childhood abuse and 63 520 were unexposed. 300 women developed MS during the follow-up period. 71 of these (24%) reported a history of childhood abuse, compared with 14 406 of 77 697 (19%) women that did not develop MS. Sexual abuse (HR 1.65, 95% CI 1.13 to 2.39) and emotional abuse (HR 1.40, 95% CI 1.03 to 1.90) in childhood were both associated with an increased risk of developing MS. The HR of MS after exposure to physical abuse was 1.31 (95% CI 0.83 to 2.06). The risk of MS was further increased if exposed to two (HR 1.66, 95% CI 1.04 to 2.67) or all three abuse categories (HR 1.93, 95% CI 1.02 to 3.67). Interpretation Childhood sexual and emotional abuse were associated with an increased risk of developing MS. The risk was higher when exposed to several abuse categories, indicating a dose–response relationship. Further studies are needed to identify underlying mechanisms.publishedVersio