Stillbirth: Women´s long-term quality of life, mental health and the subsequent pregnancy. Results from two observational studies on women with a history of stillbirth

Background: Experiencing a stillbirth is known to strongly affect women’s mental health in the short term, while the long-term impact on quality of life (QOL) and mental health remains uncertain. Psychological distress is common in the subsequent pregnancy and may be a challenge for healthcare professionals who provide guidance for these women. Interventions during childbirth, such as induced labour and elective caesarean section are more common in this group. Objectives: 1) To measure long-term QOL, well-being, depression and post-traumatic stress symptoms (PTSS) in women with a history of stillbirth, 2) to investigate experiences at the time of stillbirth and identify predictors for long-term PTSS, 3) to estimate the proportions with case-level anxiety, depression and relationship dissatisfaction during and after the subsequent pregnancy and 4) to assess healthcare utilisation, induced labour and caesarean section, and anxiety and dread of childbirth as potential mediators for these outcomes. Methods: This thesis is based on findings from two observational studies. The first study is a retrospective study including 106 women with a history of stillbirth 5-18 years previously, and 262 women with live births. The second study is a prospective cohort including 174 women pregnant after a stillbirth, 362 women pregnant after a live birth and 365 nulliparous women. Bivariate and multivariate linear and logistic regression models were used to quantify the association between previous stillbirth and the various outcomes. Results: A history of stillbirth was not associated with long-term global QOL, subjective well-being or global depression after adjustments for sociodemographic and health-related variables. The majority with a history of stillbirth had seen and held their baby and was satisfied with the support from healthcare professionals. One third showed clinically significant PTSS at follow up, while 13% scored above a (possible) post-traumatic stress disorder (PTSD) level. Risk factors for PTSS were younger age (OR 6.60, p = 0.002), induced abortion prior to stillbirth (OR 5.78, p = 0.009) and higher parity at the time of stillbirth (OR 3.46, p = 0.023). Having held the baby appeared to be protective (OR 0.17, p = 0.004). In the subsequent pregnancy, women with a previous stillbirth were at higher risk of caselevel anxiety (22.5%) and depression (19.7%) compared with women with a previous live birth (4.4% and 10.3% respectively) and previously nulliparous women (5.5% and 9.9% respectively). The differences remained significant in the multivariate analyses. Gestational age at stillbirth (> 30 weeks) and inter-pregnancy interval < 12 months were not significantly associated with case-level depression and/or anxiety. The proportions with case-level anxiety and depression were similar to the reference groups six to 18 months after the birth of a live born baby, but increased slightly 36 months postpartum. Relationship satisfaction did not differ between groups at any time point. Women pregnant after stillbirth had more frequent antenatal visits (mean 10.0 vs. 6.0 and 6.3) and more often induced labour (42.0% vs. 9.4% and 17.8%) and caesarean section (32.2% vs. 11.0% and 16.4%) compared with women with previous live births and previously nulliparous women. Anxiety was a significant, but minor, mediator for the association between previous stillbirth and frequency of antenatal visits. Dread of childbirth was not a significant mediator for the association between previous stillbirth and elective caesarean section. Conclusions: On group level, long-term QOL, well-being, and depression was not affected by a previous stillbirth in our study. However, the stillbirth clearly remains a significant event in many women´s lives as one in three women presented with clinically significant PTSS in the long term. Our findings support common guidelines that encourage women to have contact with their stillborn baby. Case-level anxiety and depression was prevalent in the subsequent pregnancy and antenatal visits, induced labour and caesarean section was more frequent. The psychosocial care provided for this group should be evaluated. Other factors than general anxiety and dread of childbirth could be stronger mediators for the high frequency of elective caesarean sections in the pregnancy after stillbirth, and this should be assessed in future studies

Antibiotikabehandling av pyelonefritt i sykehus: Implementering av den nye nasjonale retningslinjen ved medisinsk avdeling, Lovisenberg Diakonale Sykehus

Tema/Problemstilling: I 2013 ble det utgitt oppdatert nasjonal faglig retningslinje for bruk av antibiotika i sykehus. I denne oppgaven tar vi utgangspunkt i medisinsk avdeling ved Lovisenberg Diakonale sykehus hvor den nasjonale retningslinjen ikke er tatt systematisk i bruk. Det er en spesifikk bekymring angående avvik fra denne ved behandling av pyelonefritt. Det foreligger en utbredt bruk av bredspektrede cefalosporiner på bekostning av mer smalspektrede antibiotika. Dette gir unødvendige bivirkninger på kort sikt og uheldig resistensutvikling i et større tidsperspektiv. Kunnskapsgrunnlag: Kunnskapsgrunnlaget for oppgaven er et PICO-søk samt den nasjonale faglige retningslinjen som igjen tar utgangspunkt i blant annet en stor internasjonal retningslinje. Konklusjonen er at antibiotikavalg må tilpasses ut fra lokale resistensforhold. Anbefalingen om å være restriktive med cefalosporiner i Norge kommer fra et relevant norsk fagmiljø som til enhver tid oppdaterer sine anbefalinger for bruk av antibiotika i sykehus. Tiltak/kvalitetsindikator: Våre tiltak for at de ansatte skal følge retningslinjene er flere: Informasjon og undervisning, informasjonsmateriell, innføring av antibiotikaskjema og evaluering og drøfting av endringen. Vår indikator er andel pyelonefritter der det er gitt antibiotika i henhold til retningslinjen, en prosessindikator. Ledelse/organisering: Man bør opprette en arbeidsgruppe som tar ansvar for å iverksette tiltakene og evaluere effekten de første tre månedene og deretter hver tredje måned i ett år. Eventuell motstand må kartlegges og håndteres. Konklusjon: Den nasjonale retningslinjen er tydelig på at bruk av smalspektret antibiotika skal prioriteres der det er mulig. I kunnskapsgrunnlaget kommer det frem at lokale resistensforhold bør tas hensyn til. Norges gunstige resistensforhold er bakgrunnen for den norske anbefalingen om at aminoglykosider skal foretrekkes fremfor cepfalosporiner. Vi mener at våre tiltak er kostnadseffektive og medfører mindre økologiske bivirkninger enn ved dagens praksis

Psychoactive substances in natural and unnatural deaths in Norway and Sweden : a study on victims of suicide and accidents compared with natural deaths in psychiatric patients

Background: The extent of post-mortem detection of specific psychoactive drugs may differ between countries, and may greatly influence the national death register's classification of manner and cause of death. The main objective of the present study was to analyse the magnitude and pattern of post-mortem detection of various psychoactive substances by the manner of death (suicide, accidental, undetermined and natural death with a psychiatric diagnosis) in Norway and Sweden. Methods: The Cause of Death Registers in Norway and Sweden provided data on 600 deaths in 2008 from each country, of which 200 were registered as suicides, 200 as accidents or undetermined manner of death and 200 as natural deaths in individuals with a diagnosis of mental disorder as the underlying cause of death. We examined death certificates and forensic reports including toxicological analyses. Results: The detection of psychoactive substances was commonly reported in suicides (66 and 74% in Norway and Sweden respectively), accidents (85 and 66%), undetermined manner of deaths (80% in the Swedish dataset) and in natural deaths with a psychiatric diagnosis (50 and 53%). Ethanol was the most commonly reported substance in the three manners of death, except from opioids being more common in accidental deaths in the Norwegian dataset. In cases of suicide by poisoning, benzodiazepines and z-drugs were the most common substances in both countries. Heroin or morphine was the most commonly reported substance in cases of accidental death by poisoning in the Norwegian dataset, while other opioids dominated the Swedish dataset. Anti-depressants were found in 22% of the suicide cases in the Norwegian dataset and in 29% of suicide cases in the Swedish dataset. Conclusions: Psychoactive substances were detected in 66 and 74% of suicides and in 85 and 66% of accidental deaths in the Norwegian and Swedish datasets, respectively. Apart from a higher detection rate of heroin in deaths by accident in Norway than in Sweden, the pattern of detected psychoactive substances was similar in the two countries. Assessment of a suicidal motive may be hampered by the common use of psychoactive substances in suicide victims

Women's experiences in relation to stillbirth and risk factors for long-term post-traumatic stress symptoms : a retrospective study

OBJECTIVES: (1) To investigate the experiences of women with a previous stillbirth and their appraisal of the care they received at the hospital. (2) To assess the long-term level of post-traumatic stress symptoms (PTSS) in this group and identify risk factors for this outcome. DESIGN: A retrospective study. SETTING: Two university hospitals. PARTICIPANTS: The study population comprised 379 women with a verified diagnosis of stillbirth (≥23 gestational weeks or birth weight ≥500 g) in a singleton or twin pregnancy 5-18 years previously. 101 women completed a comprehensive questionnaire in two parts. PRIMARY AND SECONDARY OUTCOME MEASURES: The women's experiences and appraisal of the care provided by healthcare professionals before, during and after stillbirth. PTSS at follow-up was assessed using the Impact of Event Scale (IES). RESULTS: The great majority saw (98%) and held (82%) their baby. Most women felt that healthcare professionals were supportive during the delivery (85.6%) and showed respect towards their baby (94.9%). The majority (91.1%) had received some form of short-term follow-up. One-third showed clinically significant long-term PTSS (IES ≥ 20). Independent risk factors were younger age (OR 6.60, 95% CI 1.99 to 21.83), induced abortion prior to stillbirth (OR 5.78, 95% CI 1.56 to 21.38) and higher parity (OR 3.46, 95% CI 1.19 to 10.07) at the time of stillbirth. Having held the baby (OR 0.17, 95% CI 0.05 to 0.56) was associated with less PTSS. CONCLUSIONS: The great majority saw and held their baby and were satisfied with the support from healthcare professionals. One in three women presented with a clinically significant level of PTSS 5-18 years after stillbirth. Having held the baby was protective, whereas prior induced abortion was a risk factor for a high level of PTSS. TRIAL REGISTRATION: The study was registered at http://www.clinicaltrials.gov, with registration number NCT 00856076

Healthcare utilisation, induced labour and caesarean section in the pregnancy after stillbirth: a prospective study

Objective To investigate healthcare utilisation, induced labour and caesarean section (CS) in the pregnancy after stillbirth and assess anxiety and dread of childbirth as mediators for these outcomes. Design Population-based pregnancy cohort study. Setting The Norwegian Mother and Child Cohort Study. Sample 901 pregnant women; 174 pregnant after stillbirth, 362 pregnant after live birth and 365 previously nulliparous. Methods Data from questionnaires answered in the second and third trimesters of pregnancy and information from the Medical Birth Registry of Norway. Main outcome measures Self-reported assessment of antenatal care, register-based assessment of onset and mode of delivery. Results Women with a previous stillbirth had more frequent antenatal visits (mean 10.0; 95% confidence interval [CI] 9.4 - 10.7) compared with women with a previous live birth (6.0; 5.8 - 6.2) and previously nulliparous women (6.3; 6.1 - 6.6). Induced labour and CS, elective and emergency, were also more prevalent in the stillbirth group. The adjusted odds ratio for elective CS was 2.5 (95% CI 1.3 – 5.0) compared with women with previous live birth and 3.7 (1.8 - 7.6) compared with previously nulliparous women. Anxiety was a minor mediator for the association between stillbirth and frequency of antenatal visits, while dread of childbirth was not a significant mediator for elective CS. Conclusions Women pregnant after stillbirth were more ample users of healthcare services and had more often induced labour and CS. The higher frequency of antenatal visits and elective CS could not be accounted for by anxiety or dread of childbirth. The file is under embargo until 2018-05-1

Anxiety, depression and relationship satisfaction in the pregnancy following stillbirth and after the birth of a live-born baby : a prospective study

BACKGROUND: Experiencing a stillbirth can be a potent stressor for psychological distress in the subsequent pregnancy and possibly after the subsequent birth. The impact on women's relationship with her partner in the subsequent pregnancy and postpartum remains uncertain. The objectives of the study were 1) To investigate the prevalence of anxiety and depression in the pregnancy following stillbirth and assess gestational age at stillbirth and inter-pregnancy interval as individual risk factors. 2) To assess the course of anxiety, depression and satisfaction with partner relationship up to 3 years after the birth of a live-born baby following stillbirth. METHODS: This study is based on data from the Norwegian Mother and Child Cohort Study, a population-based pregnancy cohort. The sample included 901 pregnant women: 174 pregnant after a stillbirth, 362 pregnant after a live birth and 365 previously nulliparous. Anxiety and depression were assessed by short-form subscales of the Hopkins Symptoms Checklist, and relationship satisfaction was assessed by the Relationship Satisfaction Scale. These outcomes were measured in the third trimester of pregnancy and 6, 18 and 36 months postpartum. Logistic regression models were applied to study the impact of previous stillbirth on depression and anxiety in the third trimester of the subsequent pregnancy and to investigate gestational age and inter-pregnancy interval as potential risk factors. RESULTS: Women pregnant after stillbirth had a higher prevalence of anxiety (22.5%) and depression (19.7%) compared with women with a previous live birth (adjusted odds ratio (aOR) 5.47, 95% confidence interval (CI) 2.90-10.32 and aOR 1.91, 95% CI 1.11-3.27) and previously nulliparous women (aOR 4.97, 95% CI 2.68-9.24 and aOR 1.91, 95% CI 1.08-3.36). Gestational age at stillbirth (&gt; 30 weeks) and inter-pregnancy interval &lt;  12 months were not associated with depression and/or anxiety. Anxiety and depression decreased six to 18 months after the birth of a live-born baby, but increased again 36 months postpartum. Relationship satisfaction did not differ between groups. CONCLUSION: Women who have experienced stillbirth face a significantly greater risk of anxiety and depression in the subsequent pregnancy compared with women with a previous live birth and previously nulliparous women