Risk Estimation and Prediction of Preeclampsia, IUGR, and Thrombosis in Pregnancy

The aim of this thesis was to improve background knowledge for making a reliable medical evaluation at the first visit of a woman in her 13th gestational week, to the antenatal clinic. We have focused on the prediction and the risk estimation of preeclampsia, intra-uterine growth restriction (IUGR), and thrombosis. The thesis was based on five studies, in which we have evaluated biochemical analyzes, genetic tests, anamnestic information, and statistical information (based on the data from medical files and from the Swedish Medical Birth and Hospital Discharge Registers). High maternal urine human chorionic gonadotropin level in early pregnancy was associated with a 3-fold increased risk of preeclampsia, vis-à-vis low values, while low epidermal growth factor levels were associated with IUGR pregnancies. Maternal smoking was associated with an increased risk of thrombosis (Odds ratio (OR)=1.24; 95% Confidence interval (CI) 1.02-1.51), which was consumption dependent. Moderate smoking was associated with lower incidence of preeclampsia associated with preterm birth in both study series (OR=0.1; CI 0.01-0.7, and OR=0.6; CI 0.5-0.8, respectively). Apart from an 1.1% risk of thrombosis, APC resistance was not associated with preeclampsia, IUGR, or spontaneous abortion. However, the carriers of APC resistance had fewer profuse hemorrhages at delivery (3.7% vs. 7.9%), which might have given them an evolutionary advantage, explaining the high prevalence (10.7%). The incidence of pregnancy-associated thrombosis in Sweden was 13/10000, evenly distributed in the ante- and postpartum periods. APC resistance was associated with an 8-fold increased risk of thrombosis. Overweight, heredity of thrombosis, and cesarean delivery were all associated with a roughly 5-fold increased risk of thrombosis. Preeclampsia was associated with a 3-fold increased risk of thrombosis in the postpartum period

Reactions to awareness of activated protein C resistance carriership: a descriptive study of 270 women.

Background. Around 25 million Caucasian women are carriers of the FV Leiden mutation that causes activated protein C (APC) resistance. This is a heritable condition with a lifelong increased risk of venous thromboembolism. We performed this study to investigate women's reactions to their awareness of being APC-resistant and the consequences of this awareness. Methods. All APC-resistant women (n = 270) included in a prior study on APC resistance and pregnancy (n = 2480) were invited by written questionnaire to describe their reactions to having APC resistance, how this had changed their lives, and how they experienced our information. Answers were obtained from 215 of the 270 women (80%). Results. More than 94% of the APC-resistant women were satisfied with knowing themselves to be APC-resistant and pleased that they had enrolled in the study. Of the women on combined oral contraceptives (COC), 84% changed their method of contraception, but 16% continued on COC. One-third of the women reported becoming more worried or afraid of getting pregnant again as a result of their awareness of being APC-resistant. The proportion of women who sought legal abortions during a 2-year period after receiving this information was similar in both subgroups: 4.4% (12/270) vs. 4.3% (94/2210), p = 0.9. Conclusions. We conclude that most APC-resistant women were pleased to learn of their APC resistance status, that there was not an increased incidence of legal abortions, but almost one-third reported being more worried or afraid of getting pregnant again

Obstetric Thromboprophylaxis: The Swedish Guidelines

Obstetric thromboprophylaxis is difficult. Since 10 years Swedish obstetricians have used a combined risk estimation model and recommendations concerning to whom, at what dose, when, and for how long thromboprophylaxis is to be administrated based on a weighted risk score. In this paper we describe the background and validation of the Swedish guidelines for obstetric thromboprophylaxis in women with moderate-high risk of VTE, that is, at similar or higher risk as the antepartum risk among women with history of thrombosis. The risk score is based on major risk factors (i.e., 5-fold increased risk of thromboembolism). We present data on the efficacy of the model, the cost-effectiveness, and the lifestyle advice that is given. We believe that the Swedish guidelines for obstetric thromboprophylaxis aid clinicians in providing women at increased risk of VTE with effective and appropriate thromboprophylaxis, thus avoiding both over- and under-treatment

Individual risk assessment of thrombosis in pregnancy.

Thromboembolic complications during pregnancy are major contributors to maternal death, but there is no reliable way to estimate the absolute risk of thrombosis before the occurrence of a thromboembolic complication. OBJECTIVE: To create a model for individual estimation of thrombosis risk during pregnancy and to determine the distribution of risk estimates in a series of gravidae. METHOD AND PATIENTS: Estimates of absolute risk of pregnancy-related thromboembolism were calculated by multiplying reported figures of thrombosis incidence by prevalence-adjusted odds ratios of the following variables: smoking, parity, preeclampsia, mode of delivery, age, overweight, activated protein C resistance (FV Leiden or FV:Q506), thrombosis heredity, and previous thrombosis. We present the risk distribution among a unselected prospectively gathered cohort of 2384 unselected gravidae who were interviewed and tested for activated protein C resistance in early pregnancy. RESULTS AND CONCLUSIONS: A model for individual estimation of the absolute risk of thrombosis is presented, which is provided to the readers as a free automatic Internet-based service (http://www.riskpreg.com). As compared with antepartum, more women at high risk can be identified in the postpartum period and we suggest that this might be of use in planning the prevention of thrombosis

Cardiac arrest due to out-of-hospital pulmonary embolism during pregnancy: successful thrombolysis

Introduction: Pulmonary embolism (PE) is a rare, severe complication in pregnancy, in which case thrombolysis can be lifesaving but has risks. We aim to highlight actions specific to pregnant women. Case Description: A 24-week pregnant woman developed shortness of breath and experienced sudden cardiac arrest. Cardiopulmonary resuscitation (CPR) was begun immediately in the ambulance and a perimortem caesarean section was performed upon arrival at hospital, but the new-born died. After 55 minutes of CPR, bedside echocardiography revealed right ventricular strain and thrombolysis was given. The uterus was bandaged to minimize blood loss. After massive transfusions and correction of haemostasis, a hysterectomy was performed due to inability of the uterus to contract. After 3 weeks, the patient was discharged in good health and placed on continuous anticoagulant treatment with warfarin. Discussion: Approximately 3% of all out-of-hospital cardiac arrest cases are due to PE. Among the few patients who survive at the scene, thrombolysis can be lifesaving and should be considered in pregnant women with unstable PE. Prompt collaborative diagnostic work-up in the emergency room is necessary. In a pregnant woman with cardiac arrest, a perimortem caesarean section improves the chances of both maternal and fetal survival. Conclusion: Thrombolysis should be considered for patients with PE in pregnancy with the same indications as in a non-pregnant woman. In case of survival, there is profuse bleeding with need for massive transfusions and haemostasis correction. Despite being in very poor condition, the above patient survived and was fully restored to health

Incidence of early posterior shoulder dislocation in brachial plexus birth palsy

<p>Abstract</p> <p>Background</p> <p>Posterior dislocation of the shoulder in brachial plexus birth palsy during the first year of life is rare but the incidence increases with age. The aim was to calculate the incidence of these lesions in children below one year of age.</p> <p>Methods</p> <p>The incidence of brachial plexus birth lesion and occurrence of posterior shoulder dislocation was calculated based on a prospective follow up of all brachial plexus patients at an age below one in Malmö municipality, Sweden, 2000–2005.</p> <p>Results</p> <p>The incidence of brachial plexus birth palsy was 3.8/1000 living infants and year with a corresponding incidence of posterior shoulder dislocation (history, clinical examination and x-ray) during the first year of 0.28/1000 living infants and year, i.e. 7.3% of all brachial plexus birth palsies.</p> <p>Conclusion</p> <p>All children with a brachial plexus birth lesion (incidence 3.8‰) should be screened, above the assessment of neurological recovery, during the first year of life for posterior dislocation of the shoulder (incidence 0.28‰) since such a condition may occur in 7% of children with a brachial plexus birth lesion.</p

Epidemiological analysis of peripartum hysterectomy across nine European countries

Introduction Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high-resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries. Material and methods We performed a descriptive, multinational, population-based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section. Results A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0-10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4-12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (rho = 0.67, P < .05). Conclusions Prevalence of peripartum hysterectomy may vary considerably between high-income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine-fold increased risk of peripartum hysterectomy