Pregnancy, delivery and postpartum in women with schizophrenia or schizoaffective disorder in Finland: a national register-based comparative study.

As part of anational Finnish study on reproductive health of women with severe mental disorders, we compared pregnancy- and delivery-, and postpartum-related outcomes between women with schizophrenia (n = 3444) and those with schizoaffective disorder (n = 985), focusing on their singleton pregnancies after illness onset (n = 708 and n = 242, respectively). For comparison, data also included 22,101 controls with 3668 pregnancies. The Finnish Medical Birth Register, the Register of Congenital Malformations and the Child Welfare Register were used. Despite known differences between the two disorders, we found no robust differences between these patient groups.

Opioid maintenance treatment of pregnant women in the Scandinavian countries.

Background: WHO guidelines emphasise the need for descriptions of clinical practice and observational studies on risk and benefits of pharmacotherapies in pregnancy. The aims of the present study were to: (1) Describe opioid maintenance treatment (OMT) in the Scandinavian countries in general, and specifically for pregnant women, (2) Describe a project which utilises a new approach using registry-linkage data to examine associations between prenatal exposure to OMT and child outcomes: a Scandinavian cohort study of pregnant women in OMT during pregnancy (ScopeOMT). Data: Guidelines describing the treatment of persons with opioid use disorders in general, and specifically for pregnant women. Scandinavian registry-linkage data from ScopeOMT. Results: Registry data show that approximately 800 pregnant women received OMT during pregnancy in the period of the ScopeOMT study. Similarities across the Scandinavian countries include access to free healthcare and treatment; multidisciplinary teams trained to support pregnant women in OMT; buprenorphine as the recommended drug when initiating therapy; and a holistic focus on the patients' lives. An important difference is that Norwegian women who use illegal substances that may harm the foetus may be admitted - voluntarily, or against their will - for parts of, or the remainder of the pregnancy to inpatient treatment at specialised clinics. Conclusion: Many similarities in the treatment provided to opioid-dependent persons in the Scandinavian countries place this area in an excellent position to combine the efforts and carry out observational studies concerning the safety of OMT during pregnancy.

Schizophrenia and pregnancy: a national register-based follow-up study among Finnish women born between 1965 and 1980.

To assess psychosocial and somatic risk factors related to pregnancy, and pregnancy-related complications or disorders in women with schizophrenia compared to population controls. In this register-based cohort study, we identified all Finnish women who were born in 1965-1980 and diagnosed with schizophrenia in psychiatric care before 31 December 2013. For each case, five age- and place-of-birth matched controls were randomly selected. They were followed from the day when the disorder was diagnosed in specialized health care till the end of 2013. The mean follow-up time was 14.0 + 6.91 vs. 14.3 + 6.89 years. Altogether, 1162 singleton pregnancies were found among affected women and 4683 among controls. Affected women were significantly older and more often single; their body mass index before pregnancy was significantly higher, and they smoked significantly more often both in the beginning of pregnancy and after the first trimester than controls. They showed a significantly higher odds for pathologic oral glucose tolerance test (odds ratio (OR) 1.66, 95% confidence interval (95% CI) 1.27-2.17), initiation of insulin treatment (OR 1.84, 95% CI 1.15-2.93), fast fetal growth (OR 1.62, 95% CI 1.03-2.52), premature contractions (OR 2.42, 95% CI 1.31-4.49), hypertension (OR 1.81, 95% CI 1.01-3.27), and pregnancy-related hospitalizations (OR 1.97, 95% CI 1.66-2.33). Suspected damage to the fetus from alcohol/drugs was significantly more common among affected women than controls. Women with schizophrenia have higher prevalence of psychosocial and somatic risk factors related to pregnancy, as well as pregnancy-related complications and disorders than non-affected women.

Maternal schizophrenia and out-of-home placements of offspring: A national follow-up study among Finnish women born 1965-1980 and their children.

Schizophrenia may affect a mother's ability to parent. We investigated out-of-home placements among children with a biological mother having schizophrenia, and their relation to maternal characteristics and adverse perinatal health outcomes of the offspring. For each Finnish woman born between 1 JAN 1965 - 31 DEC 1980 and diagnosed with schizophrenia before 31 DEC 2013 (n = 5214), five matched controls were randomly selected from the Finnish Central Population Register. Children born to these women were identified and followed till 31 DEC 2013. The Child Welfare Register, the Medical Birth Register and the Register of Congenital Malformations were used to gather information. Altogether 35.1% of children with an affected mother and 3.2% of control children were placed out of home during the follow-up. The incidence rate ratio (IRR) of out-of-home placement among children with an affected mother was 12.6 (95% confidence interval (CI) 10.80-13.46) when children with a non-affected mother served as a reference. Single motherhood (IRR 2.2, 95% Cl 1.88-2.60) and maternal smoking (IRR 1.9, 95% Cl 1.68-2.16), but not an adverse perinatal outcome of the offspring, increased the risk of out-of-home placement. To conclude, maternal schizophrenia is a strong risk factor for placement of children in out-of-home care.

Obstetric and perinatal health outcomes related to schizophrenia: A national register-based follow-up study among Finnish women born between 1965 and 1980 and their offspring.

BACKGROUND: This national register-based study assesses obstetric and perinatal health outcomes in women with schizophrenia and their offspring. METHODS: Using the Care Register for Health Care, we identified Finnish women who were born in 1965- 1980 and diagnosed with schizophrenia. For each case, five age- and place-of-birth- matched controls were obtained from the Central Population Register of Finland. They were followed from the day when the disorder was diagnosed in specialized health-care (the index day) until 31.12.2013. Information related to births was obtained from the Medical Birth Register and the Register of Congenital Malformations. We focused on singleton pregnancies that led to a delivery after the index day. We restricted the analysis of deliveries in controls to those that occurred after the index day of the case. Maternal age, marital status, smoking status, sex of the newborn, and parity were used as covariates in adjusted models. RESULTS: We identified 1162 singleton births among women with schizophrenia and 4683 among controls. Schizophrenic women had a 1.4-fold increased risk of induction of labor, delivery by cesarean section, and delivery by elective cesarean section. Regarding offspring, the risk of premature birth and the risk of low Apgar score at 1 min (<7) were 1.6-fold, of resuscitation 2.5-fold, and of neonatal monitoring 2.1-fold higher. CONCLUSIONS: Schizophrenia associates with some specific delivery methods, but delivery complications are rare and their prevalence does not differ from that observed among community women. Maternal schizophrenia associates with some negative perinatal health outcomes of the offspring.

Schizophrenia and induced abortions: A national register-based follow-up study among Finnish women born between 1965-1980 with schizophrenia or schizoaffective disorder.

BACKGROUND: The objectives of this study were to investigate, in women with schizophrenia or schizoaffective disorder, the number and incidence of induced abortions (= pregnancy terminations performed by a physician), their demographic characteristics, use of contraceptives, plus indications of and complications related to pregnancy termination. METHODS: Using the Care Register for Health Care, we identified Finnish women born between the years 1965-1980 who were diagnosed with either schizophrenia or schizoaffective disorder during the follow-up period ending 31.12.2013. For each case, five age- and place-of-birth- matched controls were obtained from the Population Register of Finland. Information about births and induced abortions were obtained from the Medical Birth Register and the Induced Abortion Register. RESULTS: The number and incidence of induced abortions per 1000 follow-up years did not differ between cases and their controls. However, due to fewer pregnancies, cases exhibited an over 2-fold increased risk of pregnancy termination (RR 2.28; 95% CI 2.20-2.36). Cases were younger, were more often without a partner at the time of induced abortion, and their pregnancies resulted more often from a lack of contraception. Among cases, the indication for pregnancy termination was more often mother-to-be's medical condition. Induced abortions after 12weeks gestation were more common among cases. However, cases had no more complications related to termination. CONCLUSIONS: The incidence of induced abortions among Finnish women with schizophrenia or schizoaffective disorder is similar to the general population, but their risk per pregnancy over two-fold. They need effective, affordable family planning services and long-term premeditated contraception.

Partners of nulliparous women with severe fear of childbirth: A longitudinal study of psychological well-being.

BACKGROUND: Little is known about the psychological status of partners of women with severe fear of childbirth (FOC). In this longitudinal study from Helsinki University Central Hospital, we investigated FOC, depression, and posttraumatic stress in the partners of women with severe FOC, and possible effects of group psychoeducation and mode of birth. METHODS: During pregnancy, 250 partners of nulliparous women with severe FOC participated, 93 in the intervention group and 157 in the control group. At 3 months postpartum, 52 partners in the intervention group and 93 in the control group participated. Both the partners and the childbearing women filled in the Wijma Delivery Expectancy/Experience Questionnaire and the Edinburgh Postnatal Depression Scale mid-pregnancy as well as 3 months postpartum, when they also filled in the Traumatic Event Scale. RESULTS: Partners of women with severe FOC reported less antenatal and postnatal FOC and fewer depressive symptoms than the childbearing women. No partner reached the threshold of severe FOC. No partner reported a possible posttraumatic stress disorder. Group psychoeducation with relaxation was not associated with better or worse psychological well-being of the partners. An emergency cesarean delivery was associated with a more fearful delivery experience in the partners. CONCLUSION: Partners of nulliparous women with severe FOC neither seem to suffer from severe FOC nor reported posttraumatic stress symptoms after childbirth. They reported better psychological well-being than the mothers both during pregnancy and after delivery. An unexpected cesarean may be a negative experience even for partners of childbearing women.

Persistent Pain After Cesarean Delivery and Vaginal Delivery: A Prospective Cohort Study.

BACKGROUND: Persistent pain after cesarean delivery and vaginal delivery has been the subject of only a few research articles. The primary outcome of our prospective study was the incidence of persistent pain and its association to mode of delivery. We also studied the nature and intensity of pain after delivery. METHODS: A questionnaire was distributed on postpartum day 2 to 1052 women who had given birth vaginally and to 502 who had undergone cesarean delivery in a tertiary maternity hospital in Helsinki, Finland, in 2010. A second questionnaire was mailed to the women 1 year later. We recorded the women's health history, obstetric history and previous pain history, details of cesarean delivery or vaginal delivery, and description of pain, if present. RESULTS: The incidence of persistent pain at 1 year after delivery was greater after cesarean delivery (85/379 [22%]) than after vaginal delivery (58/713 [8%]: P < .001, relative risk 2.8, 95% confidence interval 2.0-3.8). Because of initial differences in the groups, we performed logistic regression analysis with persistent pain as a dependent factor that confirmed the mode of delivery as a predictor of persistent pain. The incidence of persistent pain graded as moderate or more severe (25/379 [7%] vs 25/713 [4%]: P = .022, relative risk 1.9, 95% confidence interval 1.1-3.2) was also greater after cesarean delivery than vaginal delivery. The incidence of persistent pain was significantly more common in women with a history of previous pain and among primiparous women in logistic regression analysis. The women with persistent pain had experienced more pain the day after cesarean delivery (P = .023) and during vaginal delivery (P = .030) than those who did not report persistent pain. Complications such as perineal trauma, episiotomy, vacuum extraction, endometritis, wound infection, or ante- or postpartum depression did not predispose women to persistent pain. Dyspareunia was reported by 41% of women after vaginal delivery and by 2% after cesarean delivery among women with persistent pain at 1 year. CONCLUSIONS: The incidence of persistent pain at 1 year is greater after cesarean delivery than after vaginal delivery. Pain shortly after cesarean delivery and during vaginal delivery correlated with persistent pain.

[Pregnancy and maternity of a schizophrenic patient]. / Skitsofreniapotilaan raskaus ja äitiys.

Aspects to be taken into consideration in the total care of women of reproductive age and affected with schizophrenia include possible contraception, pharmacological therapy during pregnancy and need for support in parenthood. Compared with other pregnant women, those affected with schizophrenia are older, are more frequently smokers during pregnancy and more often neglect health monitoring during pregnancy. Schizophrenia predisposes for preterm delivery, miscarriage and lower Apgar score of the infant. In regard to parenthood, the effects of the illness itself or the prescribed medication on the interactive mother-child relationship may emerge as problematic issues.

Monitoring the condition of the fetus during delivery.

Uterine contractions during delivery increase the resistance to flow in the blood vessels of the placenta and decreases placental blood circulation, possibly subjecting the fetus to hypoxia. Several methods have been developed for monitoring the condition of the fetus during delivery. Cardiotocography is used to monitor the fetus's heart rate and variability in relation to the mother's contractions. A change in cardiotocography recording due to stimulation of the presenting part is an indication of a healthy fetus. ST analysis of fetal ECG depicts the oxygenation of fetal cardiac muscle during delivery. In addition to cardiotocography and ST analysis, analysis of blood gases and lactate determination are used in assessing the condition of the fetus.

Diagnosis and treatment of severe hemolytic disease of the fetus and newborn: a 10-year nationwide retrospective study.

OBJECTIVE: Outcome after intrauterine transfusions due to severe hemolytic disease of the fetus and newborn. DESIGN: Nationwide population-based retrospective cohort study. SETTING: All women treated with intrauterine transfusions for hemolytic disease of the fetus and newborn in Finland in 2003-2012. POPULATION: 339 intrauterine transfusions, performed in 104 pregnancies of 84 women. METHODS: Information on antenatal screening of red cell antibodies and red cell units issued for intrauterine transfusion was obtained from the Finnish Red Cross Blood Service database, and obstetric and neonatal data from hospital records. MAIN OUTCOME MEASURES: Procedure-related complications, perinatal mortality, neonatal morbidity. RESULTS: Overall survival was 94.2% (95% confidence interval 89.7-98.7). There were four fetal and two neonatal deaths. Procedure-related fetal loss rate was 1.2% (95% confidence interval 0.04-2.4) per procedure and 3.8% (95% confidence interval 0.1-7.5) per pregnancy. Of the four procedure-related losses, three were due to technically difficult intrauterine transfusions causing infection and preterm birth. Of the live born infants, 19% (95% confidence interval 11.3-26.7) were born before 32 weeks' gestation. The incidence of severe neonatal morbidity (respiratory distress syndrome, severe cerebral injury, sepsis) was 22.2% (95% confidence interval 13.4-30.2). Poor outcome (death, severe neonatal morbidity) was negatively associated with gestational age at first transfusion (p = 0.001) and at birth (p = 0.00006). Follow-up of the infants was too incomplete to assess the neurodevelopmental outcome. CONCLUSIONS: Although overall survival is comparable with previous studies, our concern is procedure-related infections and preterm births. Close collaboration between the university hospitals is needed to ensure timely treatment, operator skills and systematic follow-up of the children.

Life satisfaction, general well-being and costs of treatment for severe fear of childbirth in nulliparous women by psychoeducative group or conventional care attendance.

OBJECTIVE: Fear of childbirth is a common reason for seeking cesarean section. It is important to consider outcomes and costs associated with alternative treatment and delivery mode. We compared well-being and costs of group psychoeducation and conventional care for fear of childbirth. DESIGN: Randomized controlled trial. POPULATION: A total of 371 nulliparous women scoring over the 95th centile in the Wijma Delivery Expectancy Questionnaire (W-DEQ) during the first trimester. SETTING: Finland, data from obstetrical patient records and questionnaires. METHODS: Randomization to group psychoeducation with relaxation (six sessions during pregnancy, one after childbirth, n = 131), or surveillance and referral on demand (n = 240). MAIN OUTCOME MEASURES: All costs in maternity care during pregnancy, delivery and postnatally according to Diagnoses Related Groups. Life satisfaction and general well-being 3 months after childbirth (by a Satisfaction with Life Scale and Well-being Visual Analogue Scale). RESULTS: The groups did not differ in total direct costs (€3786/woman in psychoeducative group and €3830/woman in control group), nor in life satisfaction or general well-being. Although only 76 (30%) of the women assigned to the surveillance were referred to special maternity care and 36 (15%) attended advanced prenatal classes, costs in the psychoeducation group did not exceed the costs of the controls, mostly because of the greater number of uncomplicated vaginal deliveries (63% vs. 47%, p = 0.005). CONCLUSIONS: Through an association with safer childbirth and equal well-being after delivery, psychoeducative group treatment for nulliparous women with fear of childbirth can be a recommended choice for the same overall costs as conventional treatment.

Group psychoeducation with relaxation for severe fear of childbirth improves maternal adjustment and childbirth experience--a randomised controlled trial.

BACKGROUND: Previous studies on the treatment of women with fear of childbirth have focused on the delivery mode. Women with fear of childbirth often suffer from anxiety and/or depression, and treatment therefore also needs to target postnatal psychological well-being and the early mother-infant relationship. METHODS: Three hundred and seventy-one nulliparous women out of 4575 scored ≥100 in prospective screening (Wijma Delivery Expectancy Questionnaire, W-DEQ-A), indicating severe fear of childbirth. These women were randomised to psychoeducative group intervention with relaxation (n = 131; six sessions during pregnancy, one postnatal) or to conventional care (n = 240) by community nurses (referral if necessary). Psycho-emotional and psychosocial evaluations [Edinburgh Postnatal Depression Scale (EPDS), social support, Maternal Adjustment and Attitudes (MAMA), Traumatic Events Scale (TES) and the Wijma Delivery Experience Questionnaire (W-DEQ-B)] were completed twice during pregnancy and/or 3 months postpartum. RESULTS: Postnatal maternal adjustment (MAMA mean score 38.1 ± 4.3 versus 35.7 ± 5.0, p = 0.001) and childbirth experience (mean W-DEQ-B sum score 63.0 ± 29 versus 73.7 ± 32, p = 0.008) were better in the intervention group compared with controls. In hierarchical regression, social support, participating in intervention, and less fearful childbirth experience predicted better maternal adjustment. The level of postnatal depressive symptoms was significantly lower in the intervention group (mean sum score 6.4 ± 5.4 versus 8.0 ± 5.9 p = 0.04). There were no differences in the frequency of post-traumatic stress symptoms between the groups. CONCLUSIONS: In nulliparous women with severe fear of childbirth, participation in a targeted psychoeducative group resulted in better maternal adjustment, a less fearful childbirth experience and fewer postnatal depressive symptoms, compared with conventional care.

Meconium drug testing reveals maternal misuse of medicinal opioids among addicted mothers.

Meconium drug testing is a non-invasive method to detect prenatal drug exposure, which can cause severe problems for the infant, indicating the need for follow-up measures to ensure the welfare of the child. Meconium samples for drug testing were collected from 143 infants as part of routine clinical work among addicted mothers. The drug testing findings were combined with medical records including clinical background and follow-up data. The substances screened for included medicinal opioids, 6-monoacetylmorphine (a metabolite of heroin), amphetamines and tetrahydrocannabinolic acid. At least one of the 13 target drugs was detected in 57 (40%) meconium samples. In 21 cases, the findings were unexpected on the basis of clinical data or denied by the mother. Medicinal opioids, especially the opioid substitution treatment drugs buprenorphine and methadone, comprised the majority of the findings of both admitted and unexpected drug misuse. Meconium drug testing methods should target not just traditional illicit drugs but also prescription drugs with misuse potential.

Two intrauterine rescue transfusions in treatment of severe fetomaternal hemorrhage in the early third trimester.

KEY CLINICAL MESSAGE: When massive fetomaternal hemorrhage is diagnosed in the early third trimester of pregnancy, serial fetal intravascular transfusion may be an alternative to immediate delivery.

Intravenous sulprostone infusion in the treatment of retained placenta.

OBJECTIVE: To analyze the effectiveness of intravenous sulprostone infusion for the treatment of retained placenta without massive primary hemorrhage among women at an university hospital over a three-year period. DESIGN: Retrospective observational study. SETTING: University teaching hospital. POPULATION: 126 consecutive women with placental retention and intravenous sulprostone infusion as primary treatment performed from October 2007 up to December 2011. METHODS: Hospital records of women who received sulprostone infusion to attempt placental expulsion were reviewed. MAIN OUTCOME MEASURES: Primary endpoints of the study were expulsion of placenta and the total amount of blood loss during delivery. RESULTS: The placenta was successfully expelled in 39.7% of cases, whereas 60.3% of women underwent manual removal of placenta. Blood loss was significantly lower in women with successful placental expulsion than in women who had manual removal of the placenta (582 ± 431 ml vs. 1275 ± 721 ml, p < 0.0001). Sulprostone infusion did not cause adverse effects or significant postpartum morbidity. CONCLUSIONS: Intravenous sulprostone infusion is safe and reduces both blood loss and the need for manual removal of the placenta.

[Cancer diagnosed during pregnancy]. / Kun syöpä todetaan raskausaikana.

The risk of contracting cancer is approximately 1 out of 1,000 pregnancies. The most common types of cancer include melanoma, cervical cancer and breast cancer. Utilization of MRI studies for radiological examination of cancer during pregnancy is recommended. Mammography and chest radiography are also allowed. Computed tomographic scanning of the abdominal region should be avoided. The prognosis during pregnancy is dependent on the extent and histologic type of the cancer. Chemotherapy can be started after the first trimester of pregnancy and terminated about one month before delivery.

Alcohol and substance abuse identified during pregnancy: maternal morbidity, child morbidity and welfare interventions.

AIM: To study the relations between postnatal maternal morbidity, child morbidity and welfare interventions in families with prenatal alcohol or substance abuse. METHODS: A register-based longitudinal retrospective cohort study. The exposed cohort included 638 children born to 524 women followed-up during pregnancy for alcohol or substance abuse 1992-2001. Non-exposed children (n = 1914) born to control women were matched for maternal age, parity, number of foetuses, month of birth and delivery hospital of the index child. Perinatal and follow-up data of both cohorts were collected from national registers until 2007. RESULTS: Postnatal maternal abuse-related healthcare utilization and use of medication were associated with child out-of-home care. Significant differences were in particular observed in the categories of maternal mental and behavioural disorders caused by psychoactive substance use as well as injury and poisoning. Maternal inpatient care for mental and behavioural disorders peaked at the time of child out-of-home care. Maternal abuse-related healthcare utilization was associated with early child healthcare utilization and use of medication for mental and behavioural disorders. These associations were largely explained by the association with child out-of-home care. CONCLUSIONS: Postnatal maternal abuse-related morbidity is associated with significant early child morbidity, use of medication and timing of out-of-home care.

Promoting positive motherhood among nulliparous pregnant women with an intense fear of childbirth: RCT intervention.

This RCT intervention among nulliparous pregnant women with an intense fear of childbirth sought to promote preparedness for childbirth and to enhance positive parenting. Pregnant women (n = 8,611) filled in a 'fear of childbirth' questionnaire. Nulliparous women with severe fear of childbirth (n = 355) were randomized into intervention (n = 131; 41 refused) and control (n = 224) groups. They rated themselves on a preparedness scale in middle and late pregnancy, and on a motherhood scale three months after childbirth. The intervention included six psycho-education group sessions during pregnancy and one after childbirth. This intervention increased the mothers' preparedness for childbirth, which predicted an increase in positive motherhood.

Early healthcare utilization and welfare interventions among children of mothers with alcohol and substance abuse: a retrospective cohort study.

AIM: Early childhood healthcare utilization, mortality and welfare interventions were studied among children of mothers with identified gestational alcohol and/or substance abuse. METHODS: Register-based retrospective cohort study. The exposed cohort consisted of 638 children born to 524 women followed up antenatally 1992-2001 at special outpatient clinics in the capital area of Finland. Nonexposed children (n = 1914) born to control women were matched for maternal age, parity, number of foetuses, month of birth and delivery hospital of the index child. Postnatal data of both cohorts were collected from national registers until 2007. RESULTS: The exposed cohort displayed twice the amount of in- and outpatient hospital care episodes compared with nonexposed children. Differences attributable to exposure were found in categories of conditions originating in the perinatal period, mental and behavioural disorders, and nonspecific factors influencing health status and contact with health services. This was reflected in amounts of reimbursements for drugs of the central nervous system, as well as special care allowances and rehabilitation for mental and behavioural disorders. The highest degree of healthcare utilization was observed among exposed children placed in out-of-home care. One-third of these children received outpatient care and one-tenth required inpatient care for a mental and behavioural disorder. No significant differences were found in early mortality. CONCLUSION: The exposed children displayed significant neonatal and early mental and behavioural healthcare utilization, and need for significant psychosocial support during their first decade of life.