Maternal asthma and early fetal growth : the MAESTRO study

Background: Several maternal conditions can affect fetal growth, and asthma during pregnancy is known to be associated with lower birth weight and shorter gestational age. Objective: In a new Swedish cohort study on maternal asthma exposure and stress during pregnancy (MAESTRO), we have assessed if there is evidence of early fetal growth restriction in asthmatic women or if a growth restriction might come later during pregnancy. Methods: We recruited women from eight antenatal clinics in Stockholm, Sweden. Questionnaires on background factors, asthma status and stress were assessed dur- ing pregnancy. The participants were asked to consent to collection of medical re- cords including ultrasound measures during pregnancy, and linkage to national health registers. In women with and without asthma, we studied reduced or increased growth by comparing the second-trimester ultrasound with first-trimester estima- tion. We defined reduced growth as estimated days below the 10th percentile and increased growth as days above the 90th percentile. At birth, the weight and length of the newborn and the gestational age was compared between women with and without asthma. Results: We enrolled 1693 participants in early pregnancy and collected data on de- liveries and ultrasound scans in 1580 pregnancies, of which 18% of the mothers had asthma. No statistically significant reduced or increased growth between different measurement points were found when women with and without asthma were com- pared; adjusted odds ratios for reduced growth between first and second trimester 1.11 95% CI (0.63–1.95) and increased growth 1.09 95% CI (0.68–1.77). Conclusion and clinical relevance: In conclusion, we could not find evidence sup- porting an influence of maternal asthma on early fetal growth in the present cohort: Although the relatively small sample size, which may enhance the risk of a type II error, it is concluded that a potential difference is likely to be very small.Swedish Research Council, Grant Number: 2018-02640The Strategic Research Program in Epidemiology at Karolinska InstitutetHjärt-LungfondenStockholms County Council (ALF-projects)Swedish Initiative for research on Microdata in the Social And Medical Sciences (SIMSAM), Grant Number: 340-2013-5867Publishe

Asthma during pregnancy in a population-based study : pregnancy complications and adverse perinatal outcomes

BACKGROUND: Asthma is one of the most common chronic diseases, and prevalence, severity and medication may have an effect on pregnancy. We examined maternal asthma, asthma severity and control in relation to pregnancy complications, labour characteristics and perinatal outcomes. METHODS: We retrieved data on all singleton births from July 1, 2006 to December 31, 2009, and prescribed drugs and physician-diagnosed asthma on the same women from multiple Swedish registers. The associations were estimated with logistic regression. RESULTS: In total, 266 045 women gave birth to 284 214 singletons during the study period. Maternal asthma was noted in 26 586 (9.4%) pregnancies. There was an association between maternal asthma and increased risks of pregnancy complications including preeclampsia or eclampsia (adjusted OR 1.15; 95% CI 1.06-1.24) and premature contractions (adj OR 1.52; 95% CI 1.29-1.80). There was also a significant association between maternal asthma and emergency caesarean section (adj OR 1.29; 95% CI 1.23-1.34), low birth weight, and small for gestational age (adj OR 1.23; 95% CI 1.13-1.33). The risk of adverse outcomes such as low birth weight increased with increasing asthma severity. For women with uncontrolled compared to those with controlled asthma the results for adverse outcomes were inconsistent displaying both increased and decreased OR for some outcomes. CONCLUSION: Maternal asthma is associated with a number of serious pregnancy complications and adverse perinatal outcomes. Some complications are even more likely with increased asthma severity. With greater awareness and proper management, outcomes would most likely improve.NonePublishe

Prenatal diagnosis in routine antenatal care : A randomised controlled trial

Nuchal translucency (NT) measurement combined with maternal age has been shown to identify women at an increased risk of carrying a fetus with Down's syndrome (DS) more accurately than does maternal age alone. The aim of this study was to evaluate more widely the effects of two different strategies for prenatal diagnosis. 39,772 women were randomised to a routine ultrasound scan at 12-14 gestational weeks (gws)(12-week group) or at 15-22 gws (18-week group). Fetal karyotyping was offered if the risk of DS according to NT screening was >= 1/250 (12-week group) or if the woman was >= 35 years old (1 8-week group). In both groups it was also offered if a fetal structural abnormality was detected at the scan, and if there had been a chromosomal disorder in a previous pregnancy. Anomaly screening was performed in both groups according to a checklist. Dating performance was assessed by comparing true gestational age in in-vitro fertilised pregnancies with gestational age according to ultrasound, using ten dating formulas. In 24 women at risk of DS >= 1/250 according to NT screening, mental reactions were explored by two interviews during pregnancy and one after delivery. Ten babies with DS were live born in the 12-week group vs. 16 in the 18-week group (0.5/1,000 vs. 0.8/1,000, n.s.). For every case of DS prenatally detected, 38 and 85 amniocenteses were performed. Excluding testing for reasons other than those defined in the study protocol, the corresponding figures were 16 and 89, respectively. Significantly more DS pregnancies were terminated or spontaneously lost in the 12-week group (45 vs. 27; p=0.04). The detection rate < 22 gws of fetuses with any lethal/severe malformation was 31% (53/169) in the 12week group, and 41% (61/149) in the 18-week group (p=0.08). In the 12-week group, 69% of fetuses with a lethal malformation were detected at the early scan. The 18week scan strategy seemed better for detecting some specific lethal/severe malformations, but the differences were not statistically significant. Pregnancy dating at 12-14 weeks was more precise than at 15-22 gws as expressed by the standard deviation of the estimates (2 vs. 3 days). Three dating formulas performed very well at both early and late dating. Our results indicate that the estimated day of delivery should be at 281 days of gestation, rather than at 280 days as used today. Women at increased risk of DS showed strong reactions of anxiety, often expressed by putting the pregnancy "on hold". In most women, this anxiety faded away after receiving normal results from fetal karyotyping. After the birth, most women would consider NT screening in a future pregnancy. Women >= 35 years old who had a risk score lower than their age-related risk were less anxious about the risk. Many women expressed a need for more information about the screening and the risk. Neither of the strategies for prenatal diagnosis evaluated is superior to the other in all respects. An alternative, with which woman may choose both scans may be optimal. A decision about what strategy to choose must be preceded by an analysis of the financial consequences. Based on experiences from this trial, it might be stated that an implementation of NT requires extensive efforts in terms of education, training, quality control, and in developing strategies to support of women with an increased risk at screening

Waterbirth in Sweden - a comparative study

INTRODUCTION: The literature describes advantages for mothers giving birth in water, but waterbirth is controversial in Sweden and has not been offered at hospitals until recently. This study aimed to describe and compare the characteristics and outcome of waterbirths with spontaneous vaginal births at the same clinics. MATERIAL AND METHODS: A retrospective cohort study was conducted on all waterbirths at two maternity units in Sweden from March 2014 to November 2015 (n=306), and a consecutively selected comparison group of 306 women having conventional spontaneous vaginal births. Logistic regression was used to analyze the primary outcome; second-degree perineal tears. RESULTS: Women giving birth in water had a lower risk of second-degree perineal tears (adj. OR 0.6 [95% CI 0.4-0.9]). Their labor was shorter (6:03 hrs. vs 7:52 hrs.) and there were significantly less interventions than in the comparison group; amniotomy (13.7% vs. 35.3%), internal cardiotocography (11.1% vs.56.8%), and augmentation with oxytocin (5.2% vs.31.3%). There were no differences in Apgar scores or admissions to neonatal intensive care unit. The experience of childbirth, measured with a numeric rating scale, was higher in the waterbirth group indicating a more positive birth experience. Three newborns born in water had an umbilical cord avulsion. CONCLUSIONS: In this low-risk population, waterbirth is associated with positive effects on perineal tears, the frequency of interventions, the duration of labor and women's birth experience. Midwives handling waterbirth should be aware of the risk of umbilical cord avulsion. This article is protected by copyright. All rights reserved

Significant effects on neonatal morbidity and mortality after regional change in management of post-term pregnancy.

Objective. To evaluate the effects on neonatal morbidity of a regional change in induction policy for post-term pregnancy from 43(+0) to 42(+0) gestational weeks (GWs). Design and setting. Nationwide retrospective register study between 2000 and 2007. Population. All singleton pregnancies with a gestational age of >41(+2) GW (n= 119,198). Methods. All Swedish counties were divided into three groups where study group allocation was designated by the proportion of pregnancies >42(+2) GW among all pregnancies of >41(+2) GW. Stockholm county formed a separate group. Main outcome measures. Perinatal morbidity. Results. In counties with the most active management, 19% of pregnancies >41(+2) GW were delivered at >42(+2) GW during 2000-2004 compared to 7.1% in 2005-2007. In the least active counties, corresponding figures were 21.0% compared to 19.4%. During 2005-2007, the odds ratios for meconium aspiration and 5-minute Apgar score of ≤6 in the least compared to most active counties, were 1.55 (95% CI: 1.03-2.33) and 1.26 (95% CI: 1.06-1.51). In Stockholm >42(+2) GW seen among pregnancies of >41(+2) decreased from 21.0% in 2000-2004 to 5.9% in 2005-2007. Reduced perinatal death risks by 48%, meconium aspiration of 51% and low Apgar scores by 31% in 2005-2007 compared with 2000-2004 were observed. Rates of operative deliveries at >41(+2) GW in Stockholm were unaltered. Conclusion. A significant reduction in perinatal morbidity was found, with no influence on operative delivery rates for post-term pregnancy in Stockholm. We advocate a nationwide change toward more active management of post-term pregnancies

Like an empowering micro-home : A qualitative study of women's experience of giving birth in water

OBJECTIVE: To describe women´s experiences and perceptions of giving birth in water. DESIGN: A qualitative study with in-depth interviews three to five months after the birth. A content analysis of the interviews was made. SETTING: One city-located hospital in Stockholm, offering waterbirth to low risk women. PARTICIPANTS: 20 women, 12 primiparas and 8 multiparas, aged 27-39. MEASUREMENTS AND FINDINGS: The overall theme emerging from the analysis was, "Like an empowering micro-home", which describes the effect of being strengthened, enabled and authorized in the birth process. Three categories were found: "Synergy between body and mind", "Privacy and discretion", and "Natural and pleasant". KEY CONCLUSIONS: The immersion in warm water provided the women with conditions that helped them to cope and feel confident during labour and birth. The homelike and limited space of a bathtub helped give a relaxed feeling of privacy, safety, control and focus for the women. IMPLICATIONS FOR PRACTICE: This study contributes to a deeper understanding of what waterbirth offers to women. For some women, waterbirth may be a way to accomplish an empowering and positive birth experience, and could work as a tool that preserves the normality of, and increases self-efficacy in, childbirth

Oxidative stress and inflammation in retained placenta : a pilot study of protein and gene expression of GPX1 and NF kappa B

Background: Retained placenta is associated with severe postpartum hemorrhage. Its etiology is unknown and its biochemistry has not been studied. We aimed to assess whether levels of the antioxidative enzyme Glutathione Peroxidase 1 (GPX1) and the transcription factor Nuclear Factor kappa beta (NF kappa beta), as markers of oxidative stress and inflammation, were affected in retained placentas compared to spontaneously released placentas from otherwise normal full term pregnancies. Methods: In a pilot study we assessed concentrations of GPX1 by ELISA and gene (mRNA) expression of GPX1, NF kappa beta and its inhibitor I kappa beta alpha, by quantitative real-time-PCR in periumbilical and peripheral samples from retained (n = 29) and non-retained (n = 31) placental tissue. Results: Median periumbilical GPX1 concentrations were 13.32 ng/ml in retained placentas and 17.96 ng/ml in nonretained placentas (p = 0.22), peripheral concentrations were 13.27 ng/ml and 19.09 ng/ml (p = 0.08). Retained placental tissue was more likely to have a low GPX1 protein concentration (OR 3.82, p = 0.02 for periumbilical and OR 3.95, p = 0. 02 for peripheral samples). Median periumbilical GPX1 gene expressions were 1.13 for retained placentas and 0.88 for non-retained placentas (p = 0.08), peripheral expression was 1.32 and 1.18 (p = 0.46). Gene expressions of NF kappa beta and I kappa beta alpha were not significantly different between retained and non-retained placental tissue. Conclusions: Women with retained placenta were more likely to have a low level of GPX1 protein concentration in placental tissue compared to women without retained placenta and retained placental tissue showed a tendency of lower median concentrations of GPX1 protein expression. This may indicate decreased antioxidative capacity as a component in this disorder but requires a larger sample to corroborate results

Risk of negative birth experience in trial of labor after cesarean delivery: A population-based cohort study.

BACKGROUND:To improve care for women going through trial of labor after cesarean (TOLAC), we need to understand their birth experience better. We investigated the association between mode of delivery on birth experience in second birth among women with a first cesarean. METHODS:A population-based cohort study based on the Swedish Pregnancy Register with 808 women with a first cesarean and eligible for TOLAC in 2014-2017. Outcomes were mean birth experience measured by visual analogue scale (VAS) score from 1-10 and having a negative birth experience defined as VAS score ≤5. Linear and logistic regression analyses were performed with β-estimates and odds ratios (OR) with 95% confidence intervals (CI). RESULTS:Mean VAS score among women with an elective repeat cesarean (n = 251 (31%)), vaginal birth (n = 388 (48%)) or unplanned repeat cesarean (n = 169 (21%)) in second birth were 8.8 (standard deviation SD 1.4), 8.0 (SD 2.0) and 7.6 (SD 2.1), respectively. Compared to women having an elective repeat cesarean, women having an unplanned repeat cesarean delivery had five-fold higher odds of negative birth experience (adjusted OR 5.0, 95% CI 1.5-16.5). Women having a first elective cesarean and a subsequent unplanned repeat cesarean delivery had the highest odds of negative birth experience (crude OR 7.3, 95% CI 1.5-35.5). CONCLUSIONS:Most women with a first cesarean scored their second birth experience as positive irrespective of mode of delivery. However, the odds of a negative birth experience increased among women having an unplanned repeat cesarean delivery, especially when the first cesarean delivery was elective