Gestational diabetes mellitus follow-up in Norwegian primary health care: a qualitative study

Background Women with gestational diabetes mellitus (GDM) have a tenfold increased risk of developing diabetes, and a high risk of recurrent GDM. Endorsing the life-course approach aiming to prevent disease and promote health across generations, the Norwegian GDM guideline recommends follow-up in primary care after delivery, with information on the increased risks, lifestyle counselling, and annual diabetes screening. Few reports exist on Norwegian women’s experiences of GDM follow-up. Aim To elucidate women’s experiences with follow-up of GDM in pregnancy and after delivery, and to explore their attitudes to diabetes risk and motivation for lifestyle changes. Design & setting Qualitative study in primary care in the region of Stavanger, Norway. Method Semi-structured in-depth interviews were conducted 24–30 months after delivery with 14 women aged 28–44 years, with a history of GDM. Data were analysed thematically. Results Most women were satisfied with the follow-up during pregnancy; however, only two women were followed-up according to the guideline after delivery. In most encounters with GPs after delivery, GDM was not mentioned. To continue the healthy lifestyle adopted in pregnancy, awareness of future risk was a motivational factor, and the women asked for tailored information on individual risk and improved support. The main themes emerging from the analysis were as follows: stigma and shame; uncertainty; gaining control and finding balance; and a need for support to sustain change. Conclusion Women experienced a lack of support for GDM in Norwegian primary care after delivery. To maintain a healthy lifestyle, women suggested being given tailored information and improved support.publishedVersio

Glycated albumin in pregnancy: LC-MS/MS-based reference interval in healthy, nulliparous Scandinavian women and its diagnostic accuracy in gestational diabetes mellitus

Glycated albumin (GA) may be a useful biomarker of glycemia in pregnancy. The aim of this study was to establish the reference interval (RI) for GA, analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS), in healthy, nulliparous pregnant women. In addition, we assessed the accuracy of GA and glycated hemoglobin A1c (HbA1c) in the diagnosis of gestational diabetes mellitus (GDM). Finally, we explored the prevalence of GDM in healthy nulliparas, comparing three diagnostic guidelines (WHO-1999, WHO-2013 and the Norwegian guideline). The study was carried out at Stavanger University Hospital, Norway, and included a study population of 147 pregnant nulliparous women. An oral glucose tolerance test (OGTT) was performed and used as the gold standard for GDM diagnosis. Blood samples for analysis of GA and HbA1c were collected at pregnancy week 24–28. A nonparametric approach was chosen for RI calculation, and receiver operating characteristic (ROC) curves were used to evaluate the diagnostic performance of GA and HbA1c. The established RI for GA in 121 pregnant women was 7.1–11.6%. The area under the ROC curves (AUCs) were 0.531 (GA) and 0.627 (HbA1c). According to the WHO-1999, WHO-2013 and the Norwegian guideline, respectively, 24 (16%), 36 (24%) and 21 (14%) women were diagnosed with GDM. Only nine women (6%) fulfilled the GDM-criteria of all guidelines. In conclusion, we established the first LC-MS/MS-based RI for GA in pregnant women. At pregnancy weeks 24–28, neither GA nor HbA1c discriminated between those with and without GDM. Different women were diagnosed with GDM using the three guidelines.publishedVersio

Glycated albumin and continuous glucose monitoring metrics across pregnancy in women with pre-gestational diabetes

Introduction: Glycated albumin (GA), a biomarker reflecting short-term glycaemia, may be useful to assess glycaemic control in pregnancy. We examined the association between GA and continuous glucose monitoring (CGM) metrics across gestation. Methods: In this prospective cohort study including 40 women with pre-gestational diabetes, blood samples for analysis of GA and glycated haemoglobin A1c (HbA1c) were collected at pregnancy week 12, 20, 24, 28, 32 and 36. In the CGM-group (n = 19), CGM data were collected from first trimester until pregnancy week 36. Receiver operating characteristic (ROC) curves were used to assess the accuracy of GA and HbA1c to detect poor glycaemic control, using CGM metrics as the reference standard. This study was conducted at Stavanger University Hospital, Norway, in 2016–2018. Results: Glycaemic control improved across gestation with more time spent in target range, coinciding with decreased glycaemic variability and lower mean GA level. There was statistically significant correlation between GA and most CGM metrics. The area under the ROC curves (AUC) for detecting time in range 25% for the pregnancy glucose target 63–140 mg/dl (3.5–7.8 mmol/L) were 0.78 and 0.82 for GA, whereas AUCs of 0.60 and 0.72 were found for HbA1c, respectively. Conclusions: Higher GA levels were associated with less time spent in target range, more time spent in the above range area and increased glycaemic variability. GA was more accurate than HbA1c to detect time above range >25% and time in range <70%.publishedVersio

Naturskadeforsikrings- og erstatningsordninger i seks land

Denne studien har kartlagt ansvarsfordelingen og viktige etater for klimatilpasning i Norge, Sverige, Finland, Tyskland, Frankrike og Canada. Rapporten presenterer ordningene for naturskadeerstatning og/eller forsikring i de nevnte landene for å avdekke hvor stor grad det ligger insentiver til forebygging, fremfor gjenoppretting, i ordningene. Rapporten er basert på en kombinasjon av dokumentstudier og dybdeintervjuer med representanter fra myndigheter og/eller forsikrings-/finansforbund i de respektive land. Kommunene har hovedansvar for gjennomføring og oppfølging av klimatilpasning i alle landene i studien. Øverste ansvarlige myndighet og involverte underorganer varierer mellom landene, men strukturen på ansvarsfordelingen har en rekke likhetstrekk. Ansvarsfordelingen er i stor grad definert, og ofte lovbestemt. Tyskland og Canada skiller seg mest ut i studien, hovedsakelig som følge av at de er forbundsstater, og at ansvarsfordelingen for klimatilpasning reflekterer dette. Klimatilpasning er et relativt nytt fokusområde sammenliknet med arbeidet for reduksjon av klimagassutslipp. EU er blitt en pådriver for klimatilpasningsarbeid i Europa og lanserte i 2013 unionens strategi for klimatilpasning. Strategien legger vekt på å styrke beslutningsgrunnlaget for klimatiltak og støtte opp om koordinering og finansiering av handling på nasjonalt nivå. Strategien legger ansvaret for utforming av tiltak til hvert enkelt medlemsland og subsidierer tiltak for å utvikle de nasjonale kunnskapsgrunnlagene som igjen legger grunnlaget for å identifisere tiltak. Dekning (kompensasjon) av naturskader på eiendom består generelt av tre deler; • Forsikring • Selvassuranse (eieren må være forberedt på å dekke kostnadene ved eventuelle skader selv) • Statlige midler fra regjeringen, departementet eller regionalt myndighetsnivå De ulike ordningene utløses av ulike skadeårsaker og skadeobjekter. Hvilke skadeårsaker og skadeobjekter de ulike ordningene dekker varierer mellom landene i studien. Grensene mellom ordningene kan være uklare, blant annet gjennom statens rolle som formell og uformell reassurandør av forsikringsselskapene. I Finland har det foreløpig ikke vært behov for å etablere et statlig sikkerhetsnett i form av regionale, nasjonale eller EU-midler. I Norge og Frankrike er naturskadeerstatnings- og forsikringsordningene delvis offentlige. Dette innebærer at ordningene er solidariske, og at forsikringspremien ikke er risikobasert. I Frankrike er kompensasjonsordningen ved naturskade organisert som et fond, finansiert av en viss andel (12 prosent) av forsikringspremiene. Denne andelen har økt over tid, og finansierer også klimatilpasningstiltak som overvåkning, kartlegging, kommunale planer, studier og informasjonsspredning, samt ekspropriasjon og evakuering. I Norge er andelen av brannforsikringspremien som øremerkes til å erstatte naturskader på 0,065 promille, men dekker primært gjenoppretting til opprinnelig standard. I Sverige, Finland, Tyskland og Canada er ordningene i all hovedsak private forsikringsordninger. I Sverige, Finland og Canada omtales forsikring av bygninger allikevel som semi-frivillig, ettersom bankene krever at låntakeren har tegnet forsikring før de innvilger lån. Dersom man ikke trenger å ta opp lån, er tegning av forsikring frivillig. Dekningsgraden i disse landene er derfor omtrent like høy som dekningsgraden i Norge og Frankrike. En privat ordning gir insentiver til forebygging gjennom egenandeler og risikobaserte premier. Samtidig kan eksistensen av et parallelt, statlig sikkerhetsnett dempe insitamentene for forebygging av naturskader. Et annet element som demper insentivene til forebygging av skade, er at det i dag er vanlig praksis blant forsikringsselskapene å dekke kostnadene til gjenoppretting ut over opprinnelig standard etter en naturskade. Noen forsikringsselskap legger inn veiledning til klimatilpasningstiltak i forsikringsavtalen, og forsikringstaker kan få avkortning dersom disse ikke er hensyntatt. Selv om det finnes enkelte insitamenter i og utenfor ordningene, vurderes det som for passivt i forhold til forventninger til effektene av klimaendringer. Det er opp til hvert enkelt forsikringsselskap å tilby ulike tilleggsforsikringer, men privat infrastruktur dekkes som regel ikke. I Norge har man en egen statlig ordning som erstatter naturskader på privat infrastruktur, som veier, kaier og moloer. Store private selskaper kan tegne egne forsikringsavtaler på infrastruktur. Dette har blitt gjort blant annet på enkelte bruer i Sverige, flytog-infrastrukturen fra Arlanda og på jernbaneinfrastrukturen i Norge. Statlige aktører er selvassurandører i alle land. Naturskadeforsikrings- og erstatningsordningene i de ulike landene er ulike, og samtlige av ordningene har nylig blitt endret eller er under endring. Det er allikevel ikke mulig å se en generell trend i utviklingen. Finland gikk fra en privat-offentlig ordning til privat ordning i 2014, samtidig som Canada er i ferd med å utvide de offentlige ordningene som følge av at det private markedet ikke tilbyr tilfredsstillende flomforsikring. Den norske ordningen er utredet, men det er foreløpig ikke blitt vedtatt noen endring. Det solidariske elementet gjør at både det norske og det franske systemet har høy kredibilitet. Andre områder hvor insentiv for klimatilpasning kan komplementere insentivene i dagens forsikrings- og erstatningsordninger inkluderer byggtekniske forskrifter og klimatilpasningslån. Byggtekniske forskrifter kan bidra til å øke insentivene for forebygging gjennom å kreve større grad av klimatilpasning. Flere land er i ferd med å revidere og inkludere klimatilpasningstiltak i de byggtekniske forskriftene, men foreløpig er det liten grad av spesifikke krav. Markedet for grønne obligasjoner er sterkt voksende, og klimatilpasningslån kan videre bli en insentivordning på lik linje med grønne lån for energieffektive bygg. Satt i sammenheng kan for eksempel forsikringspremie avhenge av tiltak som også utløser klimatilpasningslån og sertifisering av klimatilpassede bygninger. Dette krever imidlertid også en utvikling av klimatilpasningsindikatorer. En naturlig videreføring av dette studiet er å utvikle alternative utforminger av naturskadeforsikrings- og erstatningsordningen som både beholder solidaritetsprinsippet, samtidig som de gir ytterligere insentiver til forebygging av naturskader.publishedVersio

Subjective recovery from pregnancy-related pelvic girdle pain the first 6 weeks after delivery: a prospective longitudinal cohort study

Purpose The purpose of this study was to investigate the subjective recovery from pregnancy-related pelvic girdle pain (PGP) during the first 6 weeks after delivery and to detect possible risk factors for a poor recovery. Methods The participants were included in this study at the routine ultrasound examination at 18 weeks of pregnancy. The women received a weekly SMS with the question “How many days during the last week has your PGP been bothersome?” The SMS-track from the final 10 weeks of pregnancy and first 6 weeks after delivery were assessed and sorted, based on individual graphs. A total of 130 women who reported PGP during pregnancy and met for clinical examination 6 weeks after delivery were included in the study. Results In all, 83% of the women experienced substantial recovery from severe or moderate PGP within 6 weeks after delivery. Of these, 44% reported a substantial recovery already within 2 weeks after delivery. More multiparous women, women reporting PGP the year before pregnancy, and women with high pain intensity during pregnancy had a poor recovery. Conclusions The prognosis following PGP in pregnancy is good and the majority of women recovered substantially from severe and moderate pregnancy-related PGP within 6 weeks after delivery. For many women, a subjective substantial recovery occurred within 2 weeks after delivery. Predictors for a poor recovery were multiparity, PGP the year before pregnancy and a high pain intensity during pregnancy.publishedVersio

Effects of external cephalic Version for breech presentation at or near term in high-resource settings: A systematic review of randomized and non-randomized studies

Introduction: External cephalic version (ECV) for breech presentation involves manual manipulation of the fetus from breech to cephalic presentation at or near term, in an attempt to avoid breech birth. This systematic review summarizes the literature on the effects of ECV at or near term on pregnancy outcomes in high-resource settings. Methods: The MEDLINE, Embase, CINAHL, Cochrane Library, MIDIRS, and SweMED+ databases were searched for relevant articles published through April 2019, with no limitation on publication date. Clinical trials comparing the effects of ECV at ≥36 weeks, with or without tocolysis, with that of no ECV, conducted in northern, western, and central Europe, the USA, Canada, Australia, and New Zealand were eligible for inclusion. Results: Nine articles reporting on 184704 breech pregnancies were included. Pooled data showed that ECV attempts reduced the failure to achieve vaginal cephalic birth (risk ratio, RR=0.56; 95% CI: 0.45–0.71), caesarean section performance (RR=0.57; 95% CI: 0.50–0.64), and non-cephalic presentation at birth (RR=0.45; 95% CI: 0.29–0.68) compared with no ECV. ECV attempts also increased the incidence of Apgar score <7 at 5 minutes (RR=1.29; 95% CI: 1.10–1.52). Conclusions: Women for whom ECV is attempted at or near term are at reduced risk of caesarean section, non-cephalic presentation at term, and failure to achieve vaginal cephalic birth. Compared with no ECV, attempted ECV was also associated with a slightly increased risk of a low Apgar score at 5 minutes. The evidence is limited by the scarcity of high-quality research and the presence of risks of bias.publishedVersio

The Argentinian mother-and-child contaminant study: a cross-sectional study among delivering women in the cities of Ushuaia and Salta

Source at https://doi.org/10.1080/22423982.2017.1364598 .Several ongoing international multidisciplinary projects have examined linkages between environmental chemicals and health. In contrast to Arctic regions, information for the Southern Hemisphere is scarce. Because of the inherent practice of pesticide utilisation and mismanagement, food security is potentially threatened. The most vulnerable period in human life occurs during pregnancy and early childhood, thus a focus on the body burdens of PTS in pregnant or delivering women is warranted. The current study was designed to investigate health risks related to exposure to PTS and food security in two regions of Argentina (Ushuaia and Salta). Our aims were to quantify concentrations of organic and inorganic toxins in serum or whole blood of delivering women and to collect pertinent dietary and medical information. The overall study design, the basic demographic features and essential clinical chemistry findings are described in the current paper. The socioeconomic differences between the two study areas were evident. On average, the women in Ushuaia were 4 years older than those in Salta (28.8 vs. 24.7 years). Respectively, the proportion of current smokers was 4.5 vs. 9.6%; and Salta had a higher birth rate, with 15.6% being para four or more. Saltanean women reported longer breastfeeding periods. Caesarean sections were more frequent in Ushuaia, with 43% of Caesarean deliveries compared with only 6% in Salta. Employment was high in both communities. Recognised environmental pollution sources in the vicinity of participant dwellings were widespread in Salta (56.1%) compared to Ushuaia (9%). The use of pesticides for insect control in homes was most common in Salta (80%). There is an urgent need for a comprehensive assessment of exposures in areas of the Southern Hemisphere. Our data set and the planned publications of observed concentrations of inorganic and organic environmental contaminants in both mothers and their newborns will contribute to this objective

Estimation of fetal weight in pregnancies past term

Introduction: The aim of the study was to investigate the accuracy of estimating fetal weight with ultrasound in pregnancies past term, using the eSnurra algorithm. Material and methods: In all, 419 women with pregnancy length of 290 days, attending a specialist consultation at Stavanger University Hospital, Norway, were included in a prospective observational study. Fetal weight was estimated using biparietal diameter (BPD) and abdominal circumference (AC). The algorithm implemented in an electronic calculation (eSnurra) was used to compute estimated fetal weight (EFW). Results were compared with birthweight (BW). Results: The mean interval between the ultrasound examination and birth was 2 days (SD 1.4). The median difference between BW and EFW was −6 g (CI −40 to +25 g) and the median percentage error was –0.1% (95% CI −1.0 to 0.6%). The median absolute difference was 190 g (95% CI 170–207 g). The BW was within 10% of EFW in 83% (95% CI 79–87%) of cases and within 15% of EFW in 94% (95% CI 92–96%) of cases. Limits of agreement (95%) were from −553 g to +556 g. Using 5% false‐positive rates, the sensitivity in detecting macrosomic and small for gestational age fetuses was 54% (95% CI 35–72%) and 49% (95% CI 35–63%), respectively. Conclusion: The accuracy of fetal weight estimation was good. Clinicians should be aware of limitations related to prediction at the upper and lower end, and the importance of choosing appropriate cut‐off levels.publishedVersio

Skogens helsetilstand i Norge. Resultater fra skogskadeovervåkingen i 2020

Skogens helsetilstand påvirkes i stor grad av klima og værforhold, enten direkte ved tørke, frost og vind, eller indirekte ved at klimaet påvirker omfanget av soppsykdommer og insektangrep. Klimaendringene og den forventede økningen i klimarelaterte skogskader gir store utfordringer for forvaltningen av framtidas skogressurser. Det samme gjør invaderende skadegjørere, både allerede etablerte arter og nye som kan komme til Norge i nær framtid. I denne rapporten presenteres resultater fra skogskadeovervåkingen i Norge i 2020 og trender over tid