Maternal weight, weight change and perinatal outcomes: Can physical activity and gestational weight gain modify the risk?

Background: Maternal overweight and obesity increase the risk of complications during pregnancy and childbirth and are a threath to reproduction. It is of major importance to identify factors that have the potential to reduce the risk of perinatal complications associated with maternal overweight and obesity. Aims: (I) To investigate the association between maternal prepregnant body mass index (BMI) and perinatal mortality, and further to evaluate if physical activity during pregnancy modifies the association. (II) To investigate the risk of gestational diabetes mellitus (GDM) in second pregnancy by change in prepregnant BMI from first to second pregnancy, and whether BMI in first pregnancy and gestational weight gain (GWG) in second pregnancy modify the risk. (III) To estimate the association between weight change from first to second pregnancy and recurrence of GDM. Material and Methods: (I) We analyzed 77,246 singleton pregnancies in the Norwegian Mother and Child Cohort study (1999-2008), with linked data from the Medical Birth Registry of Norway (MBRN). (II) In data from the MBRN we investigated 24,198 mothers with first and second pregnancies during 2006-2014, without GDM in first pregnancy. (III) Recurrence risk of GDM was analysed in 2,763 women with GDM in their first pregnancy, and who delivered their first and second child during 2006-2014 in the MBRN and 1992-2010 in the Medical Birth Registry of Sweden. Results: (I) An increased risk of perinatal death was seen in obese (odds ratio (OR) 2.4, 95% CI (confidence interval) 1.7–3.4) and morbidly obese (OR 3.3, 95% CI 2.1– 5.1), as compared to normal weight women. In the group participating in physical activity during pregnancy, obese women had an OR of 3.2 (95% CI 2.2–4.7) for perinatal death relative to non-obese women. In the non-active group the corresponding OR was 1.8 (95% CI 1.1–2.8) for obese women, compared with nonobese women. (II) Compared to women with stable BMI (-1 to 1 BMI units’ change), women who gained weight between pregnancies had higher risk of GDM: Gaining 1 to 2 BMI units: relative risk (RR) 2.0 (95% CI 1.5-2.7), 2 to 4 units: RR 2.6 (95% CI 2.0-3.5), and ≥4 units: RR 5.4 (4.0-7.4). Risk increased both for women with BMI 2 units (RR 0.72, 95%CI, 0.59-0.89), and increased if their BMI increased by >4 units (RR 1.26, 95%CI 1.05-1.51), compared to those with stable BMI. Among women with BMI<25, the risk of GDM recurrence increased if their BMI increased by 2-4 units (RR 1.32, 95%CI 1.08-1.60) and ≥4 units (RR 1.61, 95%CI 1.28-2.02). Conclusions: (I) Prepregnant obesity was associated with a two- to three-fold increased risk of perinatal death when compared with normal weight. For women with BMI below 30, the lowest perinatal mortality was found in those performing physical activity, however, for obese women the lowest risk was found in the nonactive group. (II) The risk of GDM in second pregnancy increased by increasing interpregnancy weight gain, and more strongly among women with BMI 1 BMI unit from first to second pregnancy reduced the risk of GDM recurrence by 20-28% in overweight/obese women. Weight gain between pregnancies increased recurrence of GDM in both normal and overweight/obese women. Implications: Prepregnant BMI and interpregnancy weight change are both important to perinatal outcomes. A population strategy approach should promote healthy weight in the reproductive population from before conception and throughout the interpregnancy window. Overweight/obese women with GDM in first pregnancy, should be systematically followed up to regain a healthy weight prior to their second pregnancy. Further research on physical activity in obese women is warranted, to evaluate if guidelines on physical activity may need to be customised to obese women. In order to evaluate the role of GWG, weight at the time of the GDM diagnosis should be systematically registered in the medical birth registries

Care of the dying – The last health service Diakonhjemmet hospital, 1897-2017 (Oslo, Norway)

Worl interRAI, Leuven, 3. - 5. februar 2020. Arrangør: interRAIWe studied death and dying in a 130 years period using RAI-LTCF retrospectively. At start, the doctors had few diagnostic aids. The standard of living and medical development gradually increased. Age 80+ at death, changed from 0-63%. However, it rarely seems easy to face death, despite better palliative care.submittedVersio

Hospitalization in the last days of life - could it have been avoided?

Worl interRAI, Leuven, 3. - 5. februar 2020. Arrangør: interRAIWe assessed nursing home patient for five years, RAI-LTCF, 110 died, of those 14 were hospitalized. One has to distinguish between the chances for cure versus the start of the death process. The staff may reassure the relatives that optimal palliative care will be provided in the nursing home.submittedVersio

May Women with a Negative Co-Test at First Follow-Up Visit Return to 3-Year Screening after Treatment for Cervical Intraepithelial Neoplasia?

Background: The Norwegian Cervical Cancer Screening Programme recommends that women treated for cervical intraepithelial neoplasia (CIN) only be returned to 3-year screening after receiving two consecutive negative co-tests, 6 months apart. Here we evaluate adherence to these guidelines and assessed the residual disease, using CIN3+ as the outcome. Methods: This cross-sectional study comprised 1397 women, treated for CIN between 2014 and 2017, who had their cytology, HPV, and histology samples analyzed by a single university department of pathology. Women who had their first and second follow-up at 4–8 and 9–18 months after treatment were considered adherent to the guidelines. The follow-up ended on 31 December 2021. We used survival analysis to assess the residual and recurrent CIN3 or worse among women with one and two negative co-tests, respectively. Results: 71.8% (1003/1397) of women attended the first follow-up 4–8 months after treatment, and 38.3% were considered adherent at the second follow-up. Nearly 30% of the women had incomplete follow-up at the study end. None of the 808 women who returned to 3-year screening after two negative co-tests were diagnosed with CIN3+, whereas two such cases were diagnosed among the 887 women who had normal cytology/ASCUS/LSIL and a negative HPV test at first follow-up (5-year risk of CIN3+: 0.24, 95%, CI: 0.00–0.57 per 100 woman-years). Conclusions: The high proportion of women with incomplete follow-up at the end of the study period requires action. The risk of CIN3+ among women with normal cytology/ASCUS/LSIL and a negative HPV test at first follow-up is indicative of a return to 3-year screening

Should frail older adults be in long-term care facilities?

Home-based nursing care is relatively easy to access in Norway compared to the rest of Europe, and the threshold for applying for assistance is relatively low. The aim of the present study was to analyze factors that enable frail older adults to live in their own homes, with a low level of care burden stress. In 2015 and 2016, eight municipalities from different parts of Norway participated in a cross-sectional study. The quantitative part of the project consisted of assessing care of 71 older adults, aged ≥80 years, using a geriatric comprehensive assessment. The qualitative part consisted of semistructured telephone interviews with 14 leaders of nursing homes and home-based nursing care and interviews with 26 close relatives. In this sample, 60% of the older adults were living alone, and 79% were at risk of permanent nursing home admission; 31% stated that they would be better-off at a higher caring level, mainly due to living alone. The relatives, their resources, and motivation to provide care seemed to be crucial for how long older adults with heavy care burden could stay at home. The municipalities offered a combination of comprehensive home care, day centers, and revolving short-term stays to enable them to live at home. Conclusion: The results reveal that the need for home care services is steadily increasing. The relatives are coping with the physical care, far better than the uncertainties and worries about what could happen when the older adults stay alone. The number of beds in institutional care in each municipality depends on various factors, such as the inhabitants’ life expectancy, social aspects, geography, well-functioning eldercare pathways, competence of the health professionals, and a well-planned housing policy.publishedVersio

Risk of obstetric anal sphincter injury associated with female genital mutilation/cutting and timing of deinfibulation

Introduction: A greater risk of obstetric anal sphincter injury has been reported among African migrants in several host countries compared with the general population. To what degree female genital mutilation/cutting affects this risk is not clear. In infibulated women, deinfibulation prevents anal sphincter injury. Whether the timing of deinfibulation affects the risk, is unknown. This study aimed to investigate the risks of anal sphincter injury associated with female genital mutilation/cutting and timing of deinfibulation in Norway, and to compare the rates of anal sphincter injury in Somaliborn women and the general population. Material and methods: In a historical cohort study, nulliparous Somali-born women who had a vaginal birth in the period 1990–2014 were identified by the Medical Birth Registry of Norway and data collected from medical records. Exposures were female genital mutilation/cutting status and deinfibulation before labor, during labor or no deinfibulation. The main outcome was obstetric anal sphincter injuries. Results: Rates of obstetric anal sphincter injury did not differ significantly by female genital mutilation/cutting status (type 1–2: 10.2%, type 3: 11.3%, none: 15.2% P = 0.17). The total rate of anal sphincter injury was 10.3% compared to 5.0% among nulliparous women in the general Norwegian population. Women who underwent deinfibulation during labor had a lower risk than women who underwent deinfibulation before labor (odds ratio 0.48, 95% confidence interval 0.27–0.86, P = 0.01). Conclusions: The high rate of anal sphincter injury in Somali nulliparous women was not related to type of female genital mutilation/cutting. Deinfibulation during labor protected against anal sphincter injury, whereas deinfibulation before labor was associated with a doubled risk. Deinfibulation before labor should not be routinely recommended during pregnanc

Home care patients in four Nordic capitals – predictors of nursing home admission during one-year followup

The aim was to predict nursing home admission (NHA) for home care patients after a 12-month follow-up study. This Nordic study is derived from the aged in home care (AdHOC) project conducted in 2001–2003 with patients at 11 sites in Europe. The participants in the cohort study were randomly selected individuals, aged 65 years or older, receiving homecare in Oslo, Stockholm, Copenhagen, and Reykjavik. The Resident Assessment Instrument for Home Care (version 2.0) was used. Epidemiological and medical characteristics of patients and service utilization were recorded for 1508 home care patients (participation rate 74%). In this sample 75% were female. The mean age was 82.1 (6.9) years for men and 84.0 (6.6) for women. The most consistent predictor of NHA was receiving skilled nursing procedures at baseline (help with medication and injections, administration or help with oxygen, intravenous, catheter and stoma care, wounds and skin care) (adjusted odds ratio = 3.7, 95% confidence interval: 1.7–7.8; P < 0.001). In this Nordic material, stronger emphasizing on higher qualified nurses in a home care setting could prevent or delay NHA