Using complaints from obstetric care for improving women's birth experiences - a cross sectional study.

INTRODUCTION: Staff shortages and quality in obstetric care is a concern in most healthcare systems and a hot topic in the public debate that has centred on complaints about deficient care. However there has been a lack of empirical data to back the debate. The aim of this study was to analyse and describe complaints in obstetric care. Further, to compare the obstetric complaint pattern to complaints from women about other hospital services. MATERIALS AND METHODS: We used the Healthcare Complaints Analysis Tool to code, analyse and extract contents of obstetric complaint cases in a region of Denmark between 2016 and 2021. We compared the obstetric complaint pattern to all other hospital complaint cases in the same period regarding female patients at a large University Hospital in a cross-sectional study. RESULTS: Complaints regarding obstetric care differed from women's complaints regarding other healthcare services. Women from obstetric care raised more problems per complaint, and tended to complain more about relational issues indicated by odds for complaints about staff shortage four times higher in the obstetric care group. Women from obstetric care had a lower proportion of compensation claims. CONCLUSION: Systematic complaint analysis acknowledged women's experience in obstetric care and may point to areas that potentially need further attention. Complaints from obstetric care show that women experience deficiencies related to relational problems like recognition and individualized support compared to complaints from women receiving other hospital healthcare services.

Reduced membrane attack complex formation in umbilical cord blood during Eculizumab treatment of the mother: a case report.

BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is a disorder of the microvasculature with hemolytic anemia, thrombocytopenia and acute kidney injury. Nowadays, aHUS is successfully treated with eculizumab, a humanized, chimeric IgG2/4 kappa antibody, which binds human complement C5 and blocks generation of C5a and membrane-attack-complex. CASE PRESENTATION: A 25-year-old woman with end stage renal disease due to relapsing atypical hemolytic uremic syndrome had a relapse of the disease during pregnancy. She was treated with eculizumab. We measured reduced formation of the membrane-attack complex in newborn's umbilical cord vein blood using the sensitive and specific Palarasah-Nielsen-ELISA. CONCLUSIONS: Eculizumab treatment of the mother with end stage renal disease may cause reduced innate immunity which could render newborns more susceptible to infections.

Hyperandrogenism and phenotypes of polycystic ovary syndrome are not associated with differences in obstetric outcomes.

OBJECTIVES: To investigate obstetric outcomes in Danish women with different phenotypes of polycystic ovary syndrome (PCOS) and isolated hyperandrogenism (HA) and describe the risk of adverse obstetric outcomes in women with PCOS and HA compared to controls. DESIGN: Cohort study. SETTING: Odense University Hospital, Denmark. POPULATION: Women with PCOS were identified prospectively starting in 1997. Singleton pregnancies in women with PCOS and HA during 2003-2011 were included (n = 199). A control group was matched to the patient cohort according to date of childbirth (n = 995). METHODS: Data on clinical characteristics and obstetric outcomes were collected in patients with PCOS and HA and controls. In PCOS and HA, total and free testosterone, sex hormone binding globulin, and hemoglobin A1c were measured outside pregnancy. During pregnancy, oral glucose tolerance tests were performed in 39 patients and 123 controls according to Danish national guidelines. PCOS phenotypes were based on the Rotterdam criteria. MAIN OUTCOME MEASURES: Gestational diabetes mellitus, pregnancy-induced hypertension, preeclampsia, delivery by emergency cesarean section, preterm delivery and anthropometric measures in the newborn. RESULTS: The incidence of adverse obstetric outcomes and anthropometric measures among the newborns were comparable between different phenotypes of PCOS and patients with HA. In the oral glucose tolerance test, patients had a higher risk of gestational diabetes mellitus compared with controls; the odds ratio (95% confidence interval) was 3.3 (1.5-6.9) after adjustment for age, parity, and body mass index (p = 0.002). The incidence of other adverse obstetric outcomes was similar in patients and controls. CONCLUSIONS: Obstetric outcomes were comparable in women with different PCOS phenotypes.

Health promotion intervention among women with recent gestational diabetes mellitus: penetration, participation, and baseline findings from the Face-it randomized controlled trial.

INTRODUCTION: Face-it is a randomized controlled trial for women with recent gestational diabetes mellitus (GDM) and their families designed to evaluate the effect of a health promotion intervention on type 2 diabetes mellitus (T2DM) risk and quality of life. This study examined (1) the penetration and participation rates for the Face-it trial, (2) the characteristics of the participating women and the potential differences in characteristics according to partner participation status, and (3) representativity of the women at baseline. RESEARCH DESIGN AND METHODS: We identified women with GDM during pregnancy and invited them and their partners to a baseline examination 10-14 weeks after delivery. Representativity was assessed by comparing the baseline participants with non-participating women, the general population of women with GDM delivering in Denmark, and populations from other intervention trials. RESULTS: The penetration rate was 38.0% (867/2279) and the participation rate was 32.9% (285/867). The 285 women who attended baseline had a mean age of 32.7 (±4.8) years and body mass index (BMI) of 28.1 (±5.4) kg/m2, and 69.8% had a partner who participated. The women participating with a partner were more often primiparous, born in Denmark (82.8% vs 68.2%), were younger, and more often had a BMI ≤24.9 kg/m2 (35.7% vs 21.2%) compared with women without a partner. Compared with the general population of women with GDM in Denmark, these women broadly had similar degree of heterogeneity, but had higher rates of primiparity and singleton deliveries, and lower rates of preterm delivery and prepregnancy obesity. CONCLUSIONS: The penetration and participation rates were acceptable. We found a high rate of partner participation. Overall, women participating with a partner were comparable with those participating without a partner. Participating women were broadly similar to the general national GDM population, however with prepregnancy obesity, multiparity, preterm delivery, and multiple pregnancy being less represented. TRIAL REGISTRATION NUMBER: NCT03997773.

Home Blood Pressure for the Prediction of Preeclampsia in Women With Preexisting Diabetes.

CONTEXT: Outside of pregnancy, home blood pressure (BP) has been shown to be superior to office BP for predicting cardiovascular outcomes. OBJECTIVE: This work aimed to evaluate home BP as a predictor of preeclampsia in comparison with office BP in pregnant women with preexisting diabetes. METHODS: A prospective cohort study was conducted of 404 pregnant women with preexisting diabetes; home BP and office BP were measured in early (9 weeks) and late pregnancy (35 weeks). Discriminative performance of home BP and office BP for prediction of preeclampsia was assessed by area under the receiver operating characteristic curves (AUC). RESULTS: In total 12% (n = 49/404) developed preeclampsia. Both home BP and office BP in early pregnancy were positively associated with the development of preeclampsia (adjusted odds ratio (95% CI) per 5 mm Hg, systolic/diastolic): home BP 1.43 (1.21-1.70)/1.74 (1.34-2.25) and office BP 1.22 (1.06-1.40)/1.52 (1.23-1.87). The discriminative performance for prediction of preeclampsia was similar for early-pregnancy home BP and office BP (systolic, AUC 69.3 [61.3-77.2] vs 64.1 [55.5-72.8]; P = .21 and diastolic, AUC 68.6 [60.2-77.0] vs 66.6 [58.2-75.1]; P = .64). Similar results were seen when comparing AUCs in late pregnancy (n = 304). In early and late pregnancy home BP was lower than office BP (early pregnancy P < .0001 and late pregnancy P < .01 for both systolic and diastolic BP), and the difference was greater with increasing office BP. CONCLUSION: In women with preexisting diabetes, home BP and office BP were positively associated with the development of preeclampsia, and for the prediction of preeclampsia home BP and office BP were comparable.

Decision Threshold for Kryptor sFlt-1/PlGF Ratio in Women With Suspected Preeclampsia: Retrospective Study in a Routine Clinical Setting.

Background The objective was to evaluate predictive performance and optimal decision threshold of the Kryptor soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio when implemented for routine management of women presenting with symptoms of preeclampsia. Methods and Results Observational retrospective study of a cohort of 501 women with suspected preeclampsia after 20 weeks of gestation. Women referred to maternity ward for observation of preeclampsia had an sFlt-1/PlGF ratio test included in routine diagnostic workup. Maternal and offspring characteristic data included maternal risk factors, outcomes, delivery mode, and indication for suspected preeclampsia. Biochemical measurements to determine sFlt-1/PlGF ratio were performed using the BRAHMS/Kryptor sFlt-1/PlGF ratio immunoassays. Results were analyzed by area under receiver-operating characteristic curve. Preeclampsia occurred in 150 of 501 (30%) of symptomatic women with an sFlt-1/PlGF ratio determined before the time of diagnosis. Area under receiver-operating characteristic curve for diagnosis of early-onset preeclampsia within 1 and 4 weeks was 0.98 (95% CI, 0.96-1.00) and 0.95 (95% CI, 0.92-0.98), respectively. For late-onset preeclampsia, predictive performance within 1 and 4 weeks was lower: 0.90 (95% CI, 0.85-0.94) and 0.85 (95% CI, 0.80-0.90), respectively. The optimal single sFlt-1/PlGF ratio threshold for all preeclampsia and late-onset preeclampsia within 1 and 4 weeks was 66. The negative and positive predictive values for ruling out and ruling in developing preeclampsia within 1 week were 96% and 70%, respectively. Conclusions The Kryptor sFlt-1/PlGF ratio is a useful clinical tool ruling out and in preeclampsia within 1 week. Prediction within 4 weeks is superior for early-onset preeclampsia. A single decision threshold of 66 is indicated for use in clinical routine.

[Hepatocellular adenoma as a cause of liver rupture and intrauterine foetal death].

During pregnancy, hepatocellular adenoma HCA may grow, which increases the risk of rupture. In this case report, a 34-year-old woman at gestational age 34+ weeks was admitted to hospital with abdominal pain, hypovolaemia and intrauterine foetal death from a ruptured hepatocellular adenoma. It was successfully managed with trans-arterial embolisation and caesarean section, followed by laparoscopic liver resection four weeks later. Spontaneous liver rupture during pregnancy is associated with an increased risk of maternal and foetal mortality, and appropriate interventional radiology and surgical measures are essential for successful treatment.

[Problematic use of capsaicin patches as pain relief during labour].

Some pregnant women use capsaicin patches placed on the lower back as pain relief during labour. The effect of prescription capsaicin patches for treatment of neuropathic pain is pharmacologically documented. There are no studies on the effect of capsaicin patches on labour pain. In this case report, capsaicin patches placed on the lower back prevented epidural analgesia during labour and spinal anaesthesia for suturing of perineal rupture due to oedema and erythema of the skin. Due to lack of evidence, neuraxial anaesthesia after the use of capsaicin patches on the lower back are contraindicated.

[Perinatal care of the extremely preterm infants].

In 2018, The Danish Society of Obstetrics and Gynecology and the Danish Paediatric Society agreed on a national consensus guideline on the treatment of imminent preterm delivery prior to 25 weeks. This review summarises the recommendations: at 22 weeks transfer to a tertiary hospital, at 23 weeks tocolysis, antenatal steroid and newborn resuscitation with parental consent, if the infant is viable, and at 24 weeks caesarean section due to foetal distress. Newborn resuscitation is standard of care, unless not indicated for other reasons at 24 weeks.

Physical activity, sedentary behavior and development of preeclampsia in women with preexisting diabetes.

AIMS: To explore the association between physical activity in early pregnancy and development of preeclampsia in women with preexisting diabetes. METHODS: In a prospective cohort study of 189 women with preexisting diabetes (110 type 1 and 79 type 2 diabetes), physical activity during pregnancy including sedentary behavior was evaluated with the Pregnancy Physical Activity Questionnaire. Primary outcome was preeclampsia. Secondary outcomes were preterm delivery, large and small for gestational age infants. RESULTS: Women developing preeclampsia (n = 23) had higher diastolic blood pressure in early pregnancy (mean 82 ± 9 SD vs. 77 ± 8, p = 0.004) and were more often nulliparous (91 vs. 52%, p < 0.001) compared with the remaining women (n = 166). Total physical activity in early pregnancy was similar between the groups (median 148 metabolic equivalent of task hours per week (MET-h/week) (interquartile range 118-227) versus 153 (121-205), p = 0.97). In early pregnancy, women developing preeclampsia reported a higher level of sedentary behavior (15 MET-h/week (7-18) versus 7 (4-15); p = 0.04); however, when adjusting for parity, diastolic blood pressure and smoking, the association attenuated (p = 0.13). Total physical activity and sedentary behavior in early pregnancy were not associated with preterm delivery, large or small for gestational age infants. CONCLUSIONS: Among women with diabetes, sedentary behavior was reported higher in early pregnancy in women developing preeclampsia compared with the remaining women, while total physical activity was similar. Sedentary behavior was a predictor of preeclampsia in the univariate analysis, but not in the multiple regression analysis, and larger studies are needed to evaluate this possible modifiable risk factor. Trial registration The study was registered at ClinicalTrials.gov (ID: NCT02890836).

[Neurological symptoms in pregnant women without any diagnosed neurological disease].

The frequency of neurological symptoms in pregnant women without previously diagnosed or newly diagnosed chronic neurological disease is low (2%) but important. Diagnosis of diseases in pregnancy can be difficult due to the physiological changes during pregnancy. This review summarises the symptoms of pregnant women with either unique or especially pregnancy-related neurological disease. If these conditions are not diagnosed and treated properly, this may result in increased morbidity and higher mortality rates in these otherwise healthy women and their children.

Effect of motivational interviewing on gestational weight gain and fetal growth in pregnant women with type 2 diabetes.

Objective: To study how lifestyle coaching with motivational interviewing to improve adherence to healthy eating affects gestational weight gain and fetal growth in pregnant women with type 2 diabetes in a real-world setting. Research design and methods: A cohort study including a prospective intervention cohort of consecutive, singleton pregnant, Danish-speaking women with type 2 diabetes included between August 2015 and February 2018 and a historical reference cohort included between February 2013 and August 2015. The intervention consisted of a motivational interviewing to improve adherence to healthy eating in addition to routine care. The reference cohort received routine care only. The main outcomes were gestational weight gain and large for gestational age (LGA) infants. Results: Ninety-seven women were included in the intervention cohort and 92 in the reference cohort. Pre-pregnancy body mass index (32.8±6.9 kg/m2 vs 32.4±7.4 kg/m2, p=0.70), gestational weight gain (9.2±5.8 kg vs 10.2±5.8 kg, p=0.25), HbA1c in early pregnancy (6.7%±1.1% vs 6.5%±1.3% (50±12 mmol/mol vs 48±14 mmol/mol), p=0.32) and late pregnancy (5.9%±0.5% vs 6.0%±0.6% (41±6 mmol/mol vs 42±7 mmol/mol), p=0.34) were comparable in the two cohorts. LGA infants occurred in 20% vs 31%, p=0.07, respectively, and after adjustment for maternal characteristics 14% vs 27% delivered LGA infants (p=0.04). Birth weight z-score was 0.24±1.36 vs 0.61±1.38, p=0.06. Conclusions: Motivational interviewing to improve adherence to healthy eating in addition to routine care in pregnant women with type 2 diabetes tended to reduce fetal overgrowth without major effect on gestational weight gain. Further studies investigating the cost-benefit of enhancing motivation are needed. Trial registration number: NCT02883127.

[Diagnostics and treatment of iron deficiency in pregnancy].

Iron deficiency and iron deficiency anaemia are frequent complications to pregnancy and especially iron deficiency is underdiagnosed because of scarce symptoms. Due to the increased need for iron and the variation in iron storage in healthy pregnant women, iron supplementation should be individualised based on the level of haemoglobin and ferritin. First choice of treatment is oral iron supplementation, unless there is a failure of treatment, a known condition with malabsorption, or severe iron deficiency anaemia very close to due date. In these cases, intravenous iron may be considered.

Urine albumin is a superior predictor of preeclampsia compared to urine plasminogen in type I diabetes patients.

Pregnant women with type I diabetes mellitus (T1DM) are at increased risk of developing preeclampsia (PE). Plasminogen is aberrantly filtrated from plasma into tubular fluid in PE patients and activated to plasmin. Plasmin activates the epithelial sodium channel in the collecting ducts potentially causing impaired sodium excretion, suppression of the renin-angiotensin-aldosterone system, and hypertension in PE. The objective of the study was to test whether urinary total plasmin(ogen)/creatinine ratio and plasma concentration of aldosterone were better predictors of PE in pregnant women with T1DM compared with urine albumin and haemoglobin A1C. The design was a longitudinal observational study of 88 pregnant T1DM patients at 2 Danish centers. Spot urine- and blood samples were collected at gestational weeks 12, 20, 28, 32, and 36. U-plasmin(ogen)/creatinine ratio increased during pregnancy. In gestational week 36, the ratio was significantly increased in the T1DM patients developing PE (P < .05). P-aldosterone was significantly increased in gestational week 20 in the group developing PE (P < .05). U-albumin/creatinine ratio was significantly increased and predicted PE at all tested gestational ages. U-albumin/creatinine ratio had a stronger association with the development of PE compared to u-total plasmin(ogen)/creatinine ratio and p-aldosterone. The positive association between u-total plasmin(ogen) and development of PE late in pregnancy is compatible with involvement in PE pathophysiology. The significance of albumin in urine emphasizes the importance of preventing renal complications when planning pregnancy in patients with type I diabetes.

Pregnancy and perinatal outcomes according to surgery to conception interval and gestational weight gain in women with previous gastric bypass.

OBJECTIVE: To compare perinatal and pregnancy outcomes including adherence to the Institute of Medicine's (IOM) recommendations for gestational weight gain (GWG) in pregnant women with conception <18 months (early group) compared to ≥18 months following gastric bypass (late group). METHODS: Retrospective cohort study comprising 71 women with gastric bypass and a singleton pregnancy presenting at Odense University Hospital, November 2007-October 2013. Data were extracted from medical records and laboratory systems. The primary outcomes were timing of pregnancy and adherence to the IOM's recommendations for GWG. Secondary outcomes were birthweight, preterm delivery, cesarean section (CS), iron deficiency and post partum hemorrhage (PPH). RESULTS: Forty-three (61%) women conceived less than 18 months after gastric bypass surgery. Women in the late group had a significantly higher risk of requiring CS or receiving intravenous iron supplementation compared to the early group (57% versus 30%, p = 0.03 and 29% versus 7%, p = 0.02, respectively). Early conception was not significantly associated with insufficient GWG, preterm delivery or birthweight. Among 54 women with information on GWG, only 13 (24%) had an appropriate GWG. CONCLUSION: The majority of pregnant women with gastric bypass did not fulfill guidelines for GWG; however, this study could not support the recommendation to postpone pregnancy.

Dialysis for twins.

A 32-year-old woman with known stage-4 chronic kidney disease due to lupus nephritis presented with twin pregnancy after in vitro fertilization at a gestational age of 24 weeks + 3 days because of imminent preterm labour. Repeated ultrasound evaluations confirmed intrauterine growth restriction in both twins and polyhydramnios as the cause of imminent preterm labour. After initiation of haemodialysis treatment, ultrasound evaluation showed a significant decrease in amniotic fluids, and also reduction in blood urea nitrogen and in clinical complaints could be observed. At a gestational age of 28 weeks + 4 days, delivery was performed by Caesarean section. This case study shows that effective treatment of elevated uraemic toxins significantly reduced the morbidity risks of the twins.

[Obese pregnant women and complications in relation to pregnancy and birth]. / Overvægtige gravide og komplikationer i relation til graviditet og fødsel.

One third of the pregnant Danish women are overweight or obese. Maternal obesity is an independent risk factor for adverse maternal and foetal outcomes including infertility, miscarriage, congenital malformations, preeclampsia, gestational diabetes, complicated deliveries, caesarean section, macrosomia and childhood obesity. This article reviews the effect of maternal obesity on obstetric and neonatal outcomes and provides recommendations for management of obesity in pregnancy.

[Medical treatment of depression during pregnancy and breastfeeding]. / Medikamentel behandling af depression under graviditet eller amning.

Medical treatment of depression during pregnancy and breastfeeding often involves concern by both the patient and the doctor because of the fear of adverse reactions or malformations of the child. This article gives an updated review on how antidepressants, lithium, antipsychotics and ECT can be used during pregnancy and breastfeeding, and presents a treatment algorithm which is used at Odense University Hospital.