RESUMO
Dietary carbohydrate manipulation can be used to reduce enteric CH4 emission, but there is a lack of studies on the interaction of different types of carbohydrates that can affect feed intake and ruminal fermentation. Understanding this interaction is necessary to make the most out of CH4 mitigation feeding strategies using different dietary carbohydrates. The aim of this study was to test the effect on enteric CH4 emission, feed intake and milk production response when cows were fed either grass-clover (GCS) or corn silage (CS) as the sole forage source (55% of dry matter, DM), in combination with either barley (BAR) or dried beet pulp (DBP) as a concentrate (21.5% of DM). Twenty-four (half first and half second parity) cows were used in a crossover design with 2 periods of 21 d each, receiving 2 of 4 diets obtained from a 2 × 2 factorial arrangement of the experimental diet. Feed intake, CH4 emission metrics and milk production were recorded at the end of the experimental periods. The diets had NDF concentrations between 258 and 340 g/kg of DM, and starch concentrations between 340 and 7.45 g/kg of DM (CS-BAR and GCS-DBP, respectively). The effects of silage and concentrate on dry matter intake (DMI) were additive, with the highest feed intake in cows fed COR-BAR, followed by cows fed COR-DBP, GCS-BAR, and GCS-DBP (21.2, 19.9, 19.1, and 18.3 kg/d). Energy corrected milk (ECM) yield was not affected by silage source in first parity cows, but it was higher for cows fed CS than cows fed GCS in second parity. The effects of silage and concentrate on CH4 production (g/d), yield (g/kg of DMI) and intensity (g/kg of ECM) were not additive as cows fed GCS had similar responses regardless of the concentrate used, but cows fed CS had lower CH4 production, yield and intensity, when fed BAR instead of DBP. The lower CH4 production, yield and intensity in cows fed CS-BAR compared with other diets could be partially explained by the nonlinear relationship between ruminal VFA and carbohydrates (NDF and starch) concentration reported in literature, however, we observed a linear relationship between acetate:propionate ratio and CH4 yield, suggesting possible other effects. The effects of silage and concentrate on the ruminal VFA were additive in first parity cows, but not in second parity cows. The interaction between dietary CHO type and parity might indicate an effect of feed intake or the energy balance of the cow. Feeding cows silage and concentrate both rich in starch can result in the lowest enteric CH4 emission.
RESUMO
BACKGROUND: Pre-eclampsia is a pregnancy related disorder associated with hypertension and vascular inflammation, factors that are also involved in the pathological pathway of aortic dilatation and aneurysm development. It is, however, unknown if younger women with previous pre-eclampsia have increased aortic dimensions. We tested the hypothesis that previous pre-eclampsia is associated with increased aortic dimensions in younger women. METHODS: The study was a cross-sectional cohort study of women with previous pre-eclampsia, aged 40-55, from the PRECIOUS population matched by age and parity with women from the general population. Using contrast-enhanced CT, aortic diameters were measured in the aortic root, ascending aorta, descending aorta, at the level of the diaphragm, suprarenal aorta, and infrarenal aorta. RESULTS: 1355 women (684 with previous pre-eclampsia and 671 from the general population), with a mean (standard deviation) age of 46.9 (4.4) were included. The pre-eclampsia group had larger mean (standard deviation) aortic diameters (mm) in all measured segments from the ascending to the infrarenal aorta (ascending: 33.4 (4.0) vs. 31.4 (3.7), descending: 23.9 (2.1) vs. 23.3 (2.0), diaphragm: 20.8 (1.8) vs. 20.4 (1.8), suprarenal: 22.9 (1.9) vs. 22.0 (2.0), infrarenal: 19.3 (1.6) vs. 18.6 (1.7), p â< â0.001 for all, also after adjustment for age, height, parity, menopause, dyslipidemia, smoking and chronic hypertension. Guideline-defined ascending aortic aneurysms were found in 8 vs 2 women (p â= â0.12). CONCLUSIONS: Women with previous pre-eclampsia have larger aortic dimensions compared with women from the general population. Pre-eclampsia was found to be an independent risk factor associated with a larger aortic diameter.
RESUMO
BACKGROUND: Preeclampsia (PE), a pregnancy-induced hypertensive disorder, affects 4-5% of pregnancies worldwide. It is well known that hypertension is associated with an increased risk of arrhythmias; however, data on the association between PE and arrhythmias are sparse. METHODS: In this observational cohort study, we identified all primiparous women who gave birth in Denmark (1997-2016) using Danish nationwide registries. The women were stratified on whether they developed PE during primiparous pregnancy, and followed from primiparous pregnancy to incident arrhythmia, emigration, death, or end of study (December 31, 2018). RESULTS: A total of 523,271 primiparous women with a median age of 28 years were included and 23,367 (4.5%) were diagnosed with PE. During a median follow-up of 10.1 years, women with vs without PE were associated with a higher incidence of arrhythmias (1.42% vs 1.02%): 1) Composite of cardiac arrest, ventricular tachycardia/fibrillation, or ICD implantation (adjusted HR 1.60 [95% CI 1.14-2.24]), 2) Composite of advanced 2nd degree or 3rd degree atrioventricular block, sinoatrial dysfunction, or pacemaker implantation (adjusted HR 1.48 [95% CI 0.97-2.23]), 3) Composite of supraventricular tachyarrhythmias or extra systoles (adjusted HR 1.34 [95% CI 1.19-1.51]), 4) Composite of all the above-mentioned arrhythmias (adjusted HR 1.37 [95% CI 1.23-1.54]). CONCLUSION: Preeclamptic women were associated with a significantly and at hitherto unknown long-term increased rate of arrhythmias. This finding suggests that women with PE may benefit from cardiovascular risk assessment, screening, and preventive education.
This study examined whether preeclampsia, a condition that can occur during pregnancy and cause high blood-pressure, was linked to heart rhythm problems in first-time mothers. Women who had preeclampsia in their first pregnancy were more likely to develop heart rhythm problems later in life.This suggests that women with a history of preeclampsia might need extra attention to prevent future problems.
RESUMO
BACKGROUND: Younger women with previous preeclampsia have an increased risk of coronary atherosclerosis. It is unknown if this risk is associated with the time of onset of preeclampsia. OBJECTIVE: This study aimed to investigate if women with early-onset preeclampsia have a higher risk of coronary atherosclerosis compared with women with late-onset preeclampsia, independent of other perinatal risk factors. STUDY DESIGN: A total of 911 women with previous preeclampsia aged 35 to 55 years participated in a clinical follow-up study, including clinical examination, comprehensive questionnaires, and cardiac computed tomography scan 13 years (range, 0-28) after index pregnancy. Early- and late-onset preeclampsia were defined as gestational age at delivery of <34+0 and ≥34+0 gestational weeks, respectively. The primary outcome of the study was the presence of coronary atherosclerosis on the cardiac computed tomography. A logistic regression analysis was performed to investigate the association between time of onset of preeclampsia, perinatal risk factors, and the primary outcome. RESULTS: Women with early-onset preeclampsia (N=139) were older (46.2±5.7 vs 44.4±5.5 years; P<.001), more likely to have hypertension (51.1% vs 35.1%; P≤.001), and had a higher body mass index (27.9±6.3 vs 26.9±5.5 kg/m2; P=.051) compared with women with late-onset preeclampsia (N=772) at follow-up. The prevalence of the primary outcome (coronary atherosclerosis) on the cardiac computed tomography among women with early- and late-onset preeclampsia was 28.8% vs 22.2%, respectively (P=.088; adjusted odds ratio, 1.74; 95% confidence interval, 1.01-3.01; P=.045 after adjustment for maternal age at index pregnancy, prepregnancy body mass index, parity, diabetes in pregnancy, smoking in pregnancy, offspring birthweight and sex, and follow-up length). CONCLUSION: Women with early-onset preeclampsia had a slightly higher risk of coronary atherosclerosis compared with women with late-onset preeclampsia. However, according to the current evidence, it does not seem indicated to limit screening, diagnostic, and preventive measures for cardiovascular disease only to women with early-onset preeclampsia.
Assuntos
Doença da Artéria Coronariana , Pré-Eclâmpsia , Humanos , Feminino , Gravidez , Pré-Eclâmpsia/epidemiologia , Pré-Eclâmpsia/diagnóstico , Adulto , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/diagnóstico , Seguimentos , Pessoa de Meia-Idade , Fatores de Risco , Índice de Massa Corporal , Idade Gestacional , Tomografia Computadorizada por Raios X/métodos , Modelos LogísticosRESUMO
Enteric CH4 produced from dairy cows contributes to the emission of greenhouse gases from anthropogenic sources. Recent studies have shown that the selection of lower CH4-emitting cows is possible, but doing so would be simpler if performance measures already recorded on farm could be used, instead of measuring gas emissions from individual cows. These performance measures could be used for selection of low emitting cows. The aim of this analysis was to quantify how much of the between-cow variation in CH4 production can be explained by variation in performance measures. A dataset with 3 experiments and a total of 149 lactating dairy cows with repeated measures was used to estimate the between-cow variation (the variation between cow estimates) for performance and gas measures from GreenFeed (C-Lock, Rapid City, SD). The cow estimates were obtained with a linear mixed model with the diet within period effect as a fixed effect and the cow within experiment as a random effect. The cow estimates for CH4 production were first regressed on the performance and gas measures individually, and then performance and CO2 production measures were grouped in 3 subsets for principal component analysis and principal component regression. The variables that explained most of the between-cow variation in CH4 production were DMI (R2 = 0.44), among the performance measures, and CO2 production (R2 = 0.61), among gas measures. Grouping the measures increased the R2 to 0.53 when only performance measures were used, and to 0.66 when CO2 production was added to the significant performance measures. We found the marginal improvement to be insufficient to justify the use of grouped measures rather than an individual measure because the latter simplifies the model and avoids over-fitting. Investigation of other measures that can be explored to increase explanatory power of between-cow variation in CH4 production is briefly discussed. Finally, the use of residual CH4 as a measure for CH4 efficiency could be considered by using either DMI or CO2 production as the sole predicting variables.
Assuntos
Dieta , Lactação , Metano , Metano/biossíntese , Metano/metabolismo , Animais , Bovinos , Feminino , Dieta/veterinária , Leite/química , Leite/metabolismo , Ração Animal , Dióxido de Carbono/análiseRESUMO
The objective of the present study was to investigate the effect of individual and combined use of dietary fat, nitrate, and 3-nitrooxypropanol (3-NOP) on dairy cows' enteric methane (CH4) emission and production performance. Twenty-four primiparous and 24 multiparous Danish Holstein cows (111 ± 44.6 d in milk; mean ± standard deviation) were included in an incomplete 8 × 8 Latin square design with six 21-d periods. Dietary treatments were organized in a 2 × 2 × 2 factorial arrangement aiming for 2 levels of FAT (30 or 63 g of crude fat/kg of dry matter [DM]; LF or HF, respectively), 2 levels of NITRATE (0 or 10 g of nitrate/kg of DM; UREA or NIT, respectively), and 2 levels of 3-NOP (0 or 80 mg/kg DM; BLANK or NOP, respectively). Treatments were included in ad libitum-fed partial mixed rations in bins that automatically measured feed intake and eating behavior. Additional concentrate was offered as bait in GreenFeed units used for measurement of gas emission. For total DM intake (DMI), a FAT × NITRATE interaction showed that DMI, across parities and levels of 3-NOP, was unaffected by separate fat supplementation, but reduced by nitrate with 4.6% and synergistically decreased (significant 2-way interaction) with 13.0% when fat and nitrate were combined. Additionally, 3-NOP decreased DMI by 13.4% and the combination of 3-NOP with fat and nitrate decreased DMI in an additive way (no significant 3-way interaction). The decreasing effects on DMI were more pronounced in multiparous cows than in primiparous cows. For treatments with largest reductions in DMI, eating behavior was altered toward more frequent, but smaller meals, a slower eating rate and increased attempts to visit unassigned feed bins. Energy-corrected milk (ECM) yield increased by 6.3% with fat supplementation, whereas ECM yield did not differ among diets including nitrate (FAT × NITRATE interaction). Cows supplemented with 3-NOP had 9.0% lower ECM yield than cows fed no 3-NOP. Based on three 2-way interactions including FAT, NITRATE, and 3-NOP, the combined use of the additives resulted in antagonistic effects on CH4 reduction. A 6% to 7% reduction in CH4 yield (CH4/kg of DMI) could be ascribed to the effect of fat, a 12% to 13% reduction could be ascribed to the effect of nitrate and an 18% to 23% reduction could be ascribed to the effect of 3-NOP. Hence, no combinations of additives resulted in CH4 yield-reductions that were greater than what was obtained by separate supplementation of the most potent additive within the combination. The CH4 yield reduction potential of additives was similar between parities. Increased apparent total-tract digestibility of organic matter (OM) in cows fed combinations including nitrate or 3-NOP was a result of a NITRATE × 3-NOP interaction. Apparent total-tract digestibility of OM was also increased by fat supplementation. These increases reflected observed decreases in DMI. In conclusion, combined use of fat, nitrate, and 3-NOP in all combinations did not result in CH4 reductions that were greater than separate supplementation of the most potent additive within the combination (3-NOP > nitrate > fat). Additionally, separate supplementation of some additives and combined use of all additives reduced DMI.
Assuntos
Leite , Nitratos , Propanóis , Feminino , Bovinos , Animais , Nitratos/farmacologia , Lactação , Gorduras na Dieta/farmacologia , Metano , Dieta/veterinária , Ingestão de Alimentos , Ração Animal/análise , Rúmen , Zea maysRESUMO
Importance: As venous thromboembolism (VTE) remains one of the leading causes of maternal mortality, identifying women at increased risk of VTE is of great importance. Preeclampsia is a pregnancy-induced hypertensive disorder with generalized endothelial dysfunction. Some studies suggest that preeclampsia is associated with an increased risk of VTE, but much controversy exists. Objective: To examine the association between preeclampsia and the risk of VTE during pregnancy, during the puerperium, and after the puerperium. Design, Setting, and Participants: This observational cohort study used Danish nationwide registries to identify all eligible primiparous women who gave birth in Denmark from January 1, 1997, to December 31, 2016. The women were followed up from primiparous pregnancy to incident VTE, emigration, death, or the end of the study (December 31, 2016). Statistical analyses were carried out from January to May 2023. Exposure: Preeclampsia during primiparous pregnancy. Main Outcomes and Measure: The main outcome was incident VTE, and the secondary outcome was all-cause mortality. Results: A total of 522â¯545 primiparous women (median age, 28 years [IQR, 25-31 years]) were included, and 23â¯330 (4.5%) received a diagnosis of preeclampsia. Women with preeclampsia were of similar age to women without preeclampsia but had a higher burden of comorbidities. During a median follow-up of 10.2 years (IQR, 5.2-15.4 years), preeclampsia was associated with a higher incidence of VTE compared with no preeclampsia (incidence rate, 448.8 [95% CI, 399.9-503.5] vs 309.6 [95% CI, 300.6-319.9] per 1000 patient-years, corresponding to an unadjusted hazard ratio [HR] of 1.45 [95% CI, 1.29-1.63] and an adjusted HR of 1.43 [95% CI, 1.27-1.61]). When stratified according to the subcategories of VTE, preeclampsia was associated with an increased rate of deep vein thrombosis (unadjusted HR, 1.51 [95% CI, 1.32-1.72] and adjusted HR, 1.49 [95% CI, 1.31-1.70]) as well as pulmonary embolism (unadjusted HR, 1.39 [95% CI, 1.09-1.76]; adjusted HR, 1.36 [95% CI, 1.08-1.73]). These findings held true in landmark analyses during pregnancy, during the puerperium, and after the puerperium. Conclusions and Relevance: This cohort study suggests that preeclampsia was associated with a significantly increased risk of VTE during pregnancy, during the puerperium, and after the puerperium, even after thorough adjustment. Future studies should address how to improve the clinical management of women with a history of preeclampsia to prevent VTE.
Assuntos
Pré-Eclâmpsia , Tromboembolia Venosa , Gravidez , Feminino , Humanos , Adulto , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/complicações , Estudos de Coortes , Pré-Eclâmpsia/epidemiologia , Comorbidade , Período Pós-PartoRESUMO
BACKGROUND: For women whose first pregnancy was complicated by pre-eclampsia (PE), particularly if severe and requiring early birth, the risk of recurrence and maternal and neonatal outcomes at subsequent birth are important considerations. METHODS: In this observational cohort study, all primiparous women who gave birth in Denmark between 1997 and 2016 were identified using nationwide registries. Women were stratified by whether they developed PE and followed from date of birth until subsequent birth, emigration, death or end of study (December 2016). The cumulative incidences of subsequent birth among women with versus without PE were assessed using the Aalen-Johansen estimator. Subsequent outcomes including PE recurrence and maternal and neonatal morbidity and mortality were also examined. Factors associated with subsequent birth and recurrent PE were examined using multivariable Cox regression models. RESULTS: Among 510 615 primiparous women with singleton pregnancies, 21 683 (4.2%) developed PE, with 1819 (0.4%) being early-onset PE (birth <34 weeks). Women with PE had a lower subsequent birth rate (57.4%) compared with women without PE (61.2%), and it was considerably lower among women with early-onset PE (49.4%). Among women with PE who had a subsequent birth, the overall recurrence rate of PE was 15.8% and higher among those with early-onset PE (31.5%). The gestational age increased with a median of 3 days (IQR -5 to 14) overall and 50 days (IQR 35-67) among those with early-onset PE. Moreover, neonatal and maternal morbidity and mortality were substantially improved in a subsequent pregnancy. CONCLUSIONS: Primiparous women with PE have a significantly lower rate of a subsequent birth than women without PE, yet the absolute difference was modest. Although the overall risk of recurrent PE is 1 in 6, maternal and neonatal morbidity and mortality at subsequent birth are substantially improved.
Assuntos
Pré-Eclâmpsia , Gravidez , Recém-Nascido , Feminino , Humanos , Pré-Eclâmpsia/epidemiologia , Estudos de Coortes , Idade Gestacional , Paridade , Incidência , Resultado da Gravidez/epidemiologiaRESUMO
BACKGROUND: Preeclampsia is associated with increased risk of cardiovascular disease later in life, but studies suggest that women with previous preeclampsia are not aware of this. Little is known about how these women perceive the condition and the associated long-term risks. We examined the experiences and perceptions of preeclampsia and the increased risk of cardiovascular disease (CVD) later in life among Danish women with previous preeclampsia and their attitudes towards CVD risk screening. METHODS: Ten individual semi-structured interviews were conducted with women with previous preeclampsia. Data were analysed using thematic analysis. RESULTS: We identified six themes: 1) Experiences and perceptions of being diagnosed with preeclampsia, 2) Awareness about increased risk of CVD later in life, 3) Knowledge as a precondition for action, 4) The perception of CVD risk as being modifiable, 5) Motivators for and barriers to a healthy lifestyle, and 6) Screening for CVD. Awareness of the severity of preeclampsia was limited prior to being diagnosed. Particularly among those with few or no symptoms, preeclampsia was perceived as a non-severe condition, which was further reinforced by the experience of having received very little information. Nonetheless, some women were shocked by the diagnosis and feared for the health of the offspring. Many women also experienced physical and psychological consequences of preeclampsia. Awareness of the increased risk of later CVD was lacking; yet, when informed, the women considered this to be essential knowledge to be able to act accordingly. The risk of future CVD was perceived to be partly modifiable with a healthy lifestyle, and the women expressed a need for counselling on appropriate lifestyle changes to reduce CVD risk. Other factors were also mentioned as imperative for lifestyle changes, including social support. The women were generally positive towards potential future screening for CVD because it could provide them with information about their health condition. CONCLUSIONS: After preeclampsia, women experienced a lack of knowledge on preeclampsia and the increased risk of CVD later in life. Improved information and follow-up after preeclampsia, including guidance on CVD risk reduction and support from health professionals and family, are warranted.
Assuntos
Doenças Cardiovasculares , Pré-Eclâmpsia , Gravidez , Feminino , Humanos , Pré-Eclâmpsia/epidemiologia , Pré-Eclâmpsia/psicologia , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/prevenção & controle , Fatores de Risco , Fatores de Risco de Doenças Cardíacas , Estilo de VidaRESUMO
OBJECTIVE: To compare maternal mortality in eight countries with enhanced surveillance systems. DESIGN: Descriptive multicountry population based study. SETTING: Eight countries with permanent surveillance systems using enhanced methods to identify, document, and review maternal deaths. The most recent available aggregated maternal mortality data were collected for three year periods for France, Italy, and the UK and for five year periods for Denmark, Finland, the Netherlands, Norway, and Slovakia. POPULATION: 297 835 live births in Denmark (2013-17), 301 169 in Finland (2008-12), 2 435 583 in France (2013-15), 1 281 986 in Italy (2013-15), 856 572 in the Netherlands (2014-18), 292 315 in Norway (2014-18), 283 930 in Slovakia (2014-18), and 2 261 090 in the UK (2016-18). OUTCOME MEASURES: Maternal mortality ratios from enhanced systems were calculated and compared with those obtained from each country's office of vital statistics. Age specific maternal mortality ratios; maternal mortality ratios according to women's origin, citizenship, or ethnicity; and cause specific maternal mortality ratios were also calculated. RESULTS: Methods for identifying and classifying maternal deaths up to 42 days were very similar across countries (except for the Netherlands). Maternal mortality ratios up to 42 days after end of pregnancy varied by a multiplicative factor of four from 2.7 and 3.4 per 100 000 live births in Norway and Denmark to 9.6 in the UK and 10.9 in Slovakia. Vital statistics offices underestimated maternal mortality by 36% or more everywhere but Denmark. Age specific maternal mortality ratios were higher for the youngest and oldest mothers (pooled relative risk 2.17 (95% confidence interval 1.38 to 3.34) for women aged <20 years, 2.10 (1.54 to 2.86) for those aged 35-39, and 3.95 (3.01 to 5.19) for those aged ≥40, compared with women aged 20-29 years). Except in Norway, maternal mortality ratios were ≥50% higher in women born abroad or of minoritised ethnicity, defined variously in different countries. Cardiovascular diseases and suicides were leading causes of maternal deaths in each country. Some other conditions were also major contributors to maternal mortality in only one or two countries: venous thromboembolism in the UK and the Netherlands, hypertensive disorders in the Netherlands, amniotic fluid embolism in France, haemorrhage in Italy, and stroke in Slovakia. Only two countries, France and the UK, had enhanced methods for studying late maternal deaths, those occurring between 43 and 365 days after the end of pregnancy. CONCLUSIONS: Variations in maternal mortality ratios exist between high income European countries with enhanced surveillance systems. In-depth analyses of differences in the quality of care and health system performance at national levels are needed to reduce maternal mortality further by learning from best practices and each other. Cardiovascular diseases and mental health in women during and after pregnancy must be prioritised in all countries.
Assuntos
Doenças Cardiovasculares , Morte Materna , Suicídio , Gravidez , Humanos , Feminino , Mortalidade Materna , Europa (Continente)/epidemiologiaRESUMO
BACKGROUND: Women with previous preeclampsia have an increased risk of coronary artery disease later in life. OBJECTIVES: This study aimed to determine the prevalence of coronary atherosclerosis in younger women with previous preeclampsia in comparison with women from the general population. METHODS: Women aged 40-55 years with previous preeclampsia were matched 1:1 on age and parity with women from the general population. Participants completed an extensive questionnaire, a clinical examination, and a coronary computed tomography angiography (CTA). The main study outcome was the prevalence of any coronary atherosclerosis on coronary CTA or a calcium score >0 in case of a nondiagnostic coronary CTA. RESULTS: A total of 1,417 women, with a mean age of 47 years, were included (708 women with previous preeclampsia and 709 control subjects from the general population). Women with previous preeclampsia were more likely to have hypertension (284 [40.1%] vs 162 [22.8%]; P < 0.001), dyslipidemia (338 [47.7%] vs 296 [41.7%]; P = 0.023), diabetes mellitus (24 [3.4%] vs 8 [1.1%]; P = 0.004), and high body mass index (27.3 ± 5.7 kg/m2 vs 25.0 ± 4.2 kg/m2; P < 0.001). Cardiac computed tomography was performed in all women. The prevalence of any coronary atherosclerosis was higher in the preeclampsia group (193 [27.4%] vs 141 [20.0%]; P = 0.001) with an OR: 1.41 (95% CI: 1.08-1.85; P = 0.012) after adjustment for age, dyslipidemia, diabetes mellitus, smoking, body mass index, menopause, and parity. CONCLUSIONS: Younger women with previous preeclampsia had a slightly higher prevalence of coronary atherosclerosis compared with age- and parity-matched women from the general population. Preeclampsia remained an independent risk factor after adjustment for traditional cardiovascular risk factors. (The CoPenHagen PREeClampsia and cardIOvascUlar diSease study [CPH-PRECIOUS]; NCT03949829).
Assuntos
Doença da Artéria Coronariana , Diabetes Mellitus , Pré-Eclâmpsia , Adulto , Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/epidemiologia , Feminino , Humanos , Pessoa de Meia-Idade , Pré-Eclâmpsia/epidemiologia , Gravidez , Fatores de RiscoRESUMO
INTRODUCTION: To improve quality across levels of care, we developed a standardized care pathway (SCP) integrating palliative and oncology services for hospitalized and home-dwelling palliative cancer patients in a rural region. METHODS: A multifaceted implementation strategy was directed towards a combination of target groups. The implementation was conducted on a system level, and implementation-related activities were registered prospectively. Adult patients with advanced cancer treated with non-curative intent were included and interviewed. Healthcare leaders (HCLs) and healthcare professionals (HCPs) involved in the development of the SCP or exposed to the implementation strategy were interviewed. In addition, HCLs and HCPs exposed to the implementation strategy answered standardized questionnaires. Hospital admissions were registered prospectively. RESULTS: To assess the use of the SCP, 129 cancer patients were included. Fifteen patients were interviewed about their experiences with the patient-held record (PHR). Sixty interviews were performed among 1320 HCPs exposed to the implementation strategy. Two hundred and eighty-seven HCPs reported on their training in and use of the SCP. Despite organizational cultural differences, developing an SCP integrating palliative and oncology services across levels of care was feasible. Both HCLs and HCPs reported improved quality of care in the wake of the implementation process. Two and a half years after the implementation was launched, 28% of the HCPs used the SCP and 41% had received training in its use. Patients reported limited use and benefit of the PHR. CONCLUSION: An SCP may be a usable tool for integrating palliative and oncology services across care levels in a rural region. An extensive implementation process resulted in improvements of process outcomes, yet still limited use of the SCP in clinical practice. HCLs and HCPs reported improved quality of cancer care following the implementation process. Future research should address mandatory elements for usefulness and successful implementation of SCPs for palliative cancer patients.
When a patient has incurable cancer, it is beneficial to introduce palliative care early in the disease trajectory along with anti-cancer treatment. A standardized care pathway is a method to improve quality and reduce variation in healthcare. It can promote integrated healthcare services in palliative care, e.g. by specifying action points when the patient's situation is changing. In this study, a standardized care pathway for cancer patients with palliative care needs was developed in a rural region of Norway. The pathway focused on patients' needs and symptoms and on smooth transition between levels of care. An educational program and an information strategy were developed to ensure implementation. To evaluate the implementation, all activity regarding the implementation process was registered. Cancer patients and healthcare professionals were interviewed and answered questionnaires. One thousand three hundred and twenty healthcare professionals were exposed to the implementation strategy. One hundred and twenty-nine cancer patients were followed up according to the standardized care pathway. Despite different perspectives of care, it was feasible to develop a standardized care pathway for palliative cancer patients across care settings. A paper-based patient-held record was only found to be useful by a limited number of patients. An extensive implementation process was completed and resulted in improvements regarding healthcare professionals' experience with the quality of cancer care in the region, but limited use of the care pathway in clinical practice. Further research should identify the most important elements for usefulness and successful implementation of the care pathway.
RESUMO
OBJECTIVE: To estimate how often midwives, specialty trainees and doctors specialised in obstetrics and gynaecology are attending to specific obstetric emergencies or high-risk deliveries (obstetric events). DESIGN: A national cross-sectional study. SETTING: All hospital labour wards in Denmark. PARTICIPANTS: Midwives (n=1303), specialty trainees (n=179) and doctors specialised in obstetrics and gynaecology (n=343) working in hospital labour wards (n=21) in Denmark in 2018. METHODS: Categories of obstetric events comprised of Apgar score <7/5 min, eclampsia, emergency caesarean sections, severe postpartum haemorrhage, shoulder dystocia, umbilical cord prolapse, vaginal breech deliveries, vaginal twin deliveries and vacuum extraction. Data on number of healthcare professionals were obtained through the Danish maternity wards, the Danish Health Authority and the Danish Society of Obstetricians and Gynaecologists. We calculated the time interval between attending each obstetric event by dividing the number of events occurred with the number of healthcare professionals. OUTCOME MEASURES: The time interval between attending a specific obstetric event. RESULTS: The average time between experiencing obstetric events ranged from days to years. Emergency caesarean sections, which occur relatively frequent, were attended on average every other month by midwives, every 9 days for specialty trainees and every 17 days by specialist doctors. On average, rare events like eclampsia were experienced by midwives only every 42 years, every 6 years by specialty trainees and every 11 years by specialist doctors. CONCLUSIONS: Some obstetric events occur extremely rarely, hindering the ability to obtain and maintain the clinical skills to manage them through clinical practice alone. By assessing the frequency of a healthcare professionals attending an obstetric emergency, our study contributes to assessing the need for supplementary educational initiatives and interventions to learn and maintain clinical skills.
Assuntos
Tocologia , Obstetrícia , Estudos Transversais , Parto Obstétrico , Emergências , Feminino , Humanos , GravidezRESUMO
The incidence of haemolytic disease of the foetus or newborn (HDFN) has decreased considerably in Denmark since the introduction of routine administration of prophylactic anti-D immunoglobulin to RhD-negative pregnant women carrying a RhD-positive foetus. RhD-positive pregnant women are screened for irregular antibodies only in the first trimester of their pregnancy, as their risk of clinically relevant immunisation during pregnancy has been considered very low. This is a case report of severe undetected alloimmunisation causing fatal HDFN after the first trimester in a RhD-positive woman.
Assuntos
Anemia Hemolítica Autoimune , Eritroblastose Fetal , Eritroblastose Fetal/etiologia , Feminino , Feto , Humanos , Recém-Nascido , Isoanticorpos , Gravidez , GestantesRESUMO
The proportion of childbearing women with pre-existing chronic medical conditions (CMC) is rising. In a randomized controlled trial, we aimed to evaluate the effects of a midwife-coordinated maternity care intervention (ChroPreg) in pregnant women with CMC. The intervention consisted of three main components: (1) Midwife-coordinated and individualized care, (2) Additional ante-and postpartum consultations, and (3) Specialized known midwives. The primary outcome was the total length of hospital stay (LOS). Secondary outcomes were patient-reported outcomes measuring psychological well-being and satisfaction with maternity care, health utilization, and maternal and infant outcomes. A total of 362 women were randomized to the ChroPreg intervention (n = 131) or Standard Care (n = 131). No differences in LOS were found between groups (median 3.0 days, ChroPreg group 0.1% lower LOS, 95% CI -7.8 to 7%, p = 0.97). Women in the ChroPreg group reported being more satisfied with maternity care measured by the Pregnancy and Childbirth Questionnaire (PCQ) compared with the Standard Care group (mean PCQ 104.5 vs. 98.2, mean difference 6.3, 95% CI 3.0-10.0, p < 0.0001). In conclusion, the ChroPreg intervention did not reduce LOS. However, women in the ChroPreg group were more satisfied with maternity care.
Assuntos
Serviços de Saúde Materna , Tocologia , Obstetrícia , Feminino , Humanos , Parto , Gravidez , Gestantes , Cuidado Pré-NatalRESUMO
OBJECTIVE: Pregnancy is a time of uncertainty and worries are common. Pregnant women with somatic chronic medical conditions (SCMC) are at higher risk of adverse pregnancy outcomes and perinatal mental illness than women without SCMC. We aimed to describe the degree and content of worries in early pregnancy among Danish women with SCMC compared with women without SCMC. STUDY DESIGN: We conducted a cross-sectional study with self-reported questionnaires answered by 28,794 women from 2012â2019 during 1st trimester at a large university hospital in Denmark. MAIN OUTCOME MEASURES: We used the Cambridge Worry Scale (CWS). The outcomes of interest were the prevalence of major worry at item level (n/%) and the total CWS score (mean/SEM) as expression of the degree and content of worries. Univariate and multivariable regression analysis were performed. RESULTS: Women with SCMC reported a significantly higher total CWS score (aMD 1.50, 95% CI: 1.20-1.80). Women with SCMC were significantly more likely to report major worry in relation to own health (aOR 2.72, 95% CI: 2.43-3.08), the baby's health (aOR 1.40 95% CI 1.31-1.52), the process of giving birth (aOR 1.12, 95% CI: 1.04-1.21), the possibility of preterm labor (aOR 1.44, 95% CI: 1.28-1.63), and miscarriage (aOR 1.34, 95% CI: 1.24-1.43). CONCLUSION: Women with SCMC reported higher overall degree of worry during early pregnancy and an increased risk of major worry in relation to own health, pregnancy complications and giving birth. In antenatal care, these worries should be addressed by clinicians.
Assuntos
Ansiedade , Gestantes , Estudos Transversais , Dinamarca , Feminino , Humanos , Recém-Nascido , Parto , GravidezRESUMO
INTRODUCTION: Cardiovascular diseases have become increasingly important as a cause of maternal death in the Nordic countries. This is likely to be associated with a rising incidence of pregnant women with congenital and acquired cardiac diseases. Through audits, we aim to prevent future maternal deaths by identifying causes of death and suboptimal factors in the clinical management. MATERIAL AND METHODS: Maternal deaths in the Nordic countries from 2005 to 2017 were identified through linked registers. The national audit groups performed case assessments based on hospital records, classified the cause of death, and evaluated the standards of clinical care provided. Key messages were prepared to improve treatment. RESULTS: We identified 227 maternal deaths, giving a maternal mortality rate of 5.98 deaths per 100 000 live births. The most common cause of death was cardiovascular disease (n = 36 deaths). Aortic dissection/rupture, myocardial disease, and ischemic heart disease were the most common diagnoses. In nearly 60% of the cases, the disease was not recognized before death. In more than half of the deaths, substandard care was identified (59%). In 11 deaths (31%), improvements to care that may have made a difference to the outcome were identified. CONCLUSIONS: Between 2005 and 2017, cardiovascular diseases were the most common causes of maternal deaths in the Nordic countries. There appears to be a clear potential for a further reduction in these maternal deaths. Increased awareness of cardiac symptoms in pregnant women seems warranted.
Assuntos
Doenças Cardiovasculares/mortalidade , Morte Materna/estatística & dados numéricos , Complicações Cardiovasculares na Gravidez/mortalidade , Sistema de Registros , Adulto , Causas de Morte , Feminino , Humanos , Mortalidade Materna , Vigilância da População , Gravidez , Complicações na Gravidez/mortalidade , Países Escandinavos e NórdicosRESUMO
BACKGROUND: Angiogenic imbalance involving the placental protein soluble Fms-like tyrosine kinase-1 (sFlt-1) and cleavage of the nursing-hormone prolactin by the enzyme cathepsin D (CD) both play a role in the pathogenesis of peripartum cardiomyopathy (PPCM). We hypothesized that angiogenic imbalance and increased activity of CD have a long-lasting impact in women with PPCM. METHODS AND RESULTS: A nationwide Danish cohort of women with PPCM (PPCM group, nâ¯=â¯28), age matched women with previous preeclampsia (nâ¯=â¯28) and uncomplicated pregnancies (nâ¯=â¯28) participated in a follow-up study including biomarker analysis, exercise testing and cardiac magnetic resonance imaging. The median time to follow-up was 91 months (range 27-137 months) for the PPCM group. Levels of sFlt-1, placental growth factor, N-terminal pro-natriuretic brain peptide, and copeptin were all significantly higher in the PPCM group. More women in the PPCM group had detectable CD activity (68%) compared with the preeclampsia group (29%) and uncomplicated pregnancies group (36%) (Pâ¯=â¯.0002). Levels of angiogenic factors and biomarkers correlated inversely with maximal exercise capacity and cardiac functional parameters assessed with cardiac magnetic resonance imaging. CONCLUSIONS: Women with PPCM had higher biomarker levels and CD activity up to 7 years after diagnosis. Higher biomarker levels correlated inversely with maximal exercise capacity and markers of cardiac dysfunction suggesting that persistent angiogenic imbalance and increased CD activity is associated with residual cardiac dysfunction.
Assuntos
Cardiomiopatias , Insuficiência Cardíaca , Complicações Cardiovasculares na Gravidez , Biomarcadores , Cardiomiopatias/diagnóstico , Feminino , Seguimentos , Humanos , Período Periparto , Placenta , Fator de Crescimento Placentário , Gravidez , Complicações Cardiovasculares na Gravidez/diagnóstico por imagemRESUMO
INTRODUCTION: Pregnancy planning allows women to engage in pregnancy planning behaviors to optimize health status in the preconception period. Women with chronic medical conditions have a higher risk for adverse pregnancy outcomes and therefore preconception care is recommended. The aim was to compare pregnancy planning among women with and without chronic medical conditions, and to assess adherence to the recommended pregnancy planning behaviors on folic acid intake, physical activity and abstention from smoking and alcohol, among women with and without chronic medical conditions stratified by pregnancy planning. MATERIAL AND METHODS: A cross-sectional study with data from 28 794 pregnancies. Pregnancy planning was measured with the Swedish Pregnancy Planning Scale. Multiple Poisson regression with robust variance estimates was used to assess the associations between chronic medical condition (yes/no and main categories) and pregnancy planning, and chronic medical condition status and pregnancy planning behaviors stratified by pregnancy planning. RESULTS: In the study population, 74% reported high degree of pregnancy planning, and 22% had one or more chronic medical conditions. We found no overall association between chronic medical condition and pregnancy planning (adjusted rate ratio [RR] 1.00, 95% confidence interval [CI] 0.98-1.01). However, women with type 2 diabetes and mental illness were significantly less likely to plan their pregnancies than women without these conditions (aRR 0.73, 95% CI 0.61-0.88; aRR 0.91, 95% CI 0.87-0.96, respectively). Women with chronic medical conditions were more likely to adhere to the recommended planning behaviors; intake of folic acid, abstention from alcohol prior to pregnancy and no binge drinking in early pregnancy. CONCLUSIONS: Overall, pregnancies were highly planned. Women with chronic medical conditions did not show a higher degree of pregnancy planning than women without chronic medical conditions but were, however. more likely to adhere to the generally recommended pregnancy planning behaviors (ie intake of folic acid and abstention from alcohol intake). Only women with mental illness and type 2 diabetes reported a lower degree of pregnancy planning. It is important that we continuously address pregnancy planning and planning behaviors for both women with and women without chronic medical conditions, especially women with type 2 diabetes and mental illness.