Factors in early pregnancy predicting pregnancy-related pain in the second and third trimester.

INTRODUCTION: Pain during pregnancy affects women's well-being, causes worry and is a risk factor for the child and the mother during labor. The aim was to investigate the relative importance of an extensive set of pregnancy-related physiological symptoms and psychosocial factors assessed in the first trimester compared with the occurrence of pregnancy-related pain symptoms later in the pregnancy. MATERIAL AND METHODS: Included were all women who booked an appointment for a first prenatal visit in one of 125 randomly selected general practitioner practices in Eastern Denmark from April 2015 to August 2016. These women answered an electronic questionnaire containing questions on the occurrence of five pregnancy-related pain symptoms: back pain, leg cramps, pelvic cavity pain, pelvic girdle pain and uterine contractions. The questionnaire also included sociodemographic questions and questions on chronic diseases, physical symptoms, mental health symptoms, lifestyle and reproductive background. The questionnaire was repeated in each trimester. The relative importance of this set of factors from the first trimester on the five pregnancy-related pain symptoms compared with the second and third trimesters was assessed in a dominance analysis. RESULTS: A total of 1491 women were included. The most important factor for pregnancy-related pain in the second trimester and third trimester is the presence of the corresponding pain in the first trimester. Parity was associated with pelvic cavity pain and uterine contractions in the following pregnancies. For back pain and pelvic cavity pain, the odds increased as the women's estimated low self-assessed fitness decreased and had low WHO-5 wellbeing scores. CONCLUSIONS: When including physical risk factors, sociodemographic factors, psychological factors and clinical risk factors, women's experiences of pregnancy-related pain in the first trimester are the most important predictors for pain later in pregnancy. Beyond the expected positive effects of pregnancy-related pain, notably self-assessed fitness, age and parity were predictive for pain later in pregnancy.

The effect of disease onset chronology on mortality among patients with multimorbidity: A Danish nationwide register study.

Background: Multimorbidity is associated with increased mortality. Certain combinations of diseases are known to be more lethal than others, but the limited knowledge of how the chronology in which diseases develop impacts mortality may impair the development of effective clinical interventions for patients with multimorbidity. Objective: To explore if in multimorbidity the chronology of disease onset is associated with mortality. Design: A prospective nationwide cohort study, including 3,986,209 people aged ≥18 years on 1 January 2000, was performed. We included ten diagnosis groups: lung, musculoskeletal, endocrine, mental, cancer, neurological, gastrointestinal, cardiovascular, kidney, and sensory organs. We defined multimorbidity as the presence of at least two diagnoses from two diagnosis groups (out of ten). To determine mortality, logistic regression models were used to calculate odds ratios (OR) and ratio of ORs (RORs). Results: For most combinations of multimorbidity, the chronology of disease onset does not change mortality. However, when multimorbidity included mental health diagnoses, mortality was in general higher if the mental health diagnosis appeared first. If multimorbidity included heart and sensory diagnoses, mortality was higher if these developed second. For the majority of multimorbidity combinations, there was excess mortality if multimorbidity was diagnosed simultaneously, rather than consecutively, for example, heart and kidney (3.58 ROR; CI 2.39-5.36), or mental health and musculoskeletal diagnoses (2.38 ROR; CI 1.70-3.32). Conclusions: Overall, in multimorbidity, the chronology in which diseases develop is not associated with mortality, with few exceptions. For almost all combinations of multimorbidity, diagnoses act synergistically in relation to mortality if diagnosed simultaneously.

Mental vulnerability before and depressive symptoms during pregnancy and postpartum: a prospective population-based cohort study from general practice.

PURPOSE: The aim was to investigate and compare the prevalence of symptoms of depression throughout pregnancy and postpartum among women who at the first pregnancy consultation had (1) record of mental disease, (2) self-reported psychological difficulties but no record of mental disease, or (3) no mental vulnerability. MATERIALS AND METHODS: Prospective cohort study. An electronic questionnaire containing the Major Depression Inventory (MDI) was e-mailed to 1494 pregnant women after the first, second and third prenatal care consultation and eight weeks postpartum. High depression score was considered present with MDI scores of 21 or more. Information on sociodemographic, somatic comorbidities and previous psychiatric disorders was collected. We used logistic regression to estimate odds ratios with 95% confidence intervals. RESULTS: The overall prevalence of symptoms of depression (MDI ≥ 21) dropped throughout pregnancy. At the first prenatal care consultation the prevalence was 15.3%, 10.7% in the second trimester, 9.3% in the third trimester and 5.6% postpartum. Logistic regression showed increased risk of symptoms of depression throughout pregnancy and postpartum for both women with mental disease and psychological difficulties. For each outcome, the increase in odds for the psychological difficulties group was about one third of the increase in odds for the mental illness group. CONCLUSIONS: Self-reported psychological difficulties may indicate higher odds of depressive symptoms. The healthcare staff meeting the pregnant women in early pregnancy have a good opportunity to identify this subgroup of vulnerable women by means of the Pregnancy Health Records and additional questions exploring women's experiences with previous psychological difficulties.

Selection bias in general practice research: analysis in a cohort of pregnant Danish women.

OBJECTIVE: The aim of the present study was to examine selection in a general practice-based pregnancy cohort. DESIGN: Survey linked to administrative register data. SETTING AND SUBJECTS: In spring 2015, GPs were recruited from two Danish regions. They were asked to invite all pregnant women in their practice who had their first prenatal care visit before 15 August 2016 to participate in the survey. OUTCOME MEASURES: The characteristics of GPs and the pregnant women were compared at each step in the recruitment process - the GP's invitation, their agreement to participate, actual GP participation, and the women's participation - with an uncertainty coefficient to quantify the step where the largest selection occurs. RESULTS: Significant differences were found between participating and non-participating practices with regards to practice characteristics such as the number of patients registered with the practice, the age and sex of doctors, and the type of practice. Despite these differences, the characteristics of the eligible patients differed little between participating and non-participating practices. In participating practices significant differences were, however, observed between recruited and non-recruited patients. CONCLUSION: The skewed selection of patients was mainly caused by a high number of non-participants within practices that actively took part in the study. We recommend that a focus on the sampling within participating practices be the most important factor in representative sampling of patient populations in general practice. Key points Selection among general practitioners (GPs) is often unavoidable in practice-based studies, and we found significant differences between participating and non-participating practices. These include practice characteristics such as the number of GPs, the number of patients registered with the GP practice, as well as the sex and age of the GPs. •Despite this, only small differences in the characteristics of the eligible patients were observed between participating and non-participating practices. •In participating practices, however, significant differences were observed between recruited and non-recruited patients. •Comprehensive sampling within participating practices may be the best way to generate representative samples of patients.

Sleep complaints in early pregnancy. A cross-sectional study among women attending prenatal care in general practice.

BACKGROUND: Sleep problems in late pregnancy are common, but sleep in early pregnancy is less well described. The aim of this study was to describe the occurrence and severity of sleep complaints in early pregnancy. We asked the women about worries due to sleep problems. Furthermore, we investigated the associations between sleep complaints and pregnancy-related symptoms. This association was studied taking into account physical and mental health, sociodemographic characteristics, and reproductive history of the women. METHODS: Cross-sectional study in Danish general practice based on an electronic questionnaire completed by pregnant women and a Pregnancy Health Record filled in by the general practitioner (GP). The questionnaire measured three sleep complaints and 11 common physical pregnancy-related symptoms. The sleep complaints were measured as mild, moderate or severe, and it was recorded how much they worried the women. The associations between the physical pregnancy-related symptoms and sleep complaints were assessed by odds ratios from multivariable logistic regression models. RESULTS: The questionnaire was completed by 1338 out of 1508 eligible women before the end of gestation week 16. The gestational age ranged from 5 to 16 weeks (median 11 weeks) among the included women. On average, more than one third of the women reported to have at least one of the three sleep complaints in the questionnaire. Problems "taking a long time to fall asleep" was reported by 312 women (23%), "waking up too early" was reported by 629 (47%), and 183 (14%) had been "lying awake most of the night". One sleep complaint was reported by 38%, two by 16, and 4% had all three symptoms. The majority were not at all or only mildly worried because of their sleep disturbances, but moderate or severe worries were found among 46% of those" taking a long time to fall asleep" and among 40% of those "lying awake most of the night". "Moderate or severe complaints" were reported by 277 (21%) women "Moderate or severe complaints" were associated with pregnancy-related physical symptoms, such as back pain, pelvic girdle pain and pelvic cavity pain, but only the association with pelvic cavity pain stayed significant after adjustment for depression. CONCLUSION: This study showed that sleep complaints in early pregnancy are common, and sleep complaints showed association with physical as well as mental symptoms. It may be important for pregnant patients that clinicians address depression, and mood in relation to sleep problems during pregnancy.

Examining to what extent pregnancy-related physical symptoms worry women in the first trimester of pregnancy: a cross-sectional study in general practice.

BACKGROUND: Women often wish to discuss their pregnancy symptoms with their GP. However, the two parties' understanding of symptoms may not be aligned. AIM: To examine to what degree a specific pregnancy-related symptom worried women in the first trimester and analyse the characteristics of the most worried women. DESIGN & SETTING: A cross-sectional study was performed in general practice in Denmark from 1 March 2015-15 August 2016. METHOD: Women attending the first prenatal care visit completed a questionnaire about pregnancy-related physical symptoms and worries. Women were recruited from 125 GP practices and 294 GPs participated in the study. Further data were obtained from their pregnancy health record. Multivariable logistic regression analysis was used to assess the associations between the women's worries and the severity of the symptoms, which were adjusted for age and parity. RESULTS: A total of 1508 women, aged 16-45 years, were included and 1455 completed the questionnaire. Nausea, vomiting, pelvic cavity pain, and back pain were the most common symptoms, and 88% reported having two or more symptoms simultaneously. Among the 1278 women reporting nausea, only 21% were worried, while 88% of the 252 women reporting vaginal bleeding were worried. Primigravidae (those pregnant for the first time) were significantly more worried about vomiting and nausea than multigravidae (those who have experienced pregnancy previously). Those aged >35 years were more worried about pelvic girdle pain and pelvic cavity pain than younger women. CONCLUSION: Pregnancy-related physical symptoms are frequent in the first trimester. The severity of worries depends on the symptom. Vaginal bleeding and pain give rise to the majority of severe worries, especially among young women.

Physical discomfort in early pregnancy and postpartum depressive symptoms.

PURPOSE: Pregnancy examinations conducted in general practice focus mainly on identifying high-risk pregnancies and pregnancy complications. The pregnancy health record has a biomedical focus, and consequently the woman's mental well-being may receive less attention. The aim of this study was to evaluate the extent to which early pregnancy-related symptoms should be considered as indicators of an increased risk of postpartum depression. MATERIALS AND METHODS: For a prospective cohort of 1508 pregnant women, the presence of 11 pregnancy-related symptoms was recorded at the first prenatal care consultation together with background information about socio-demography and health. Depression was assessed 8 weeks postpartum with the major depression inventory (MDI) and depression was considered present if MDI > 20. Multivariable logistic regression was used to assess the association between pregnancy-related symptoms and postpartum depressive symptoms, and to adjust for potential confounders. RESULTS: A high depression score (MDI score >20) 8 weeks postpartum was found among 6.6% of the women and showed apparent associations with physical discomfort in early pregnancy, such as back pain and pelvic cavity pain. Analysis of confounding revealed, however, that signs of vulnerable mental health, present in early pregnancy, explained most of these associations. CONCLUSIONS: Indicators of an increased risk of postpartum depressive symptoms may be found in early pregnancy. Pregnancy-related pain in the first trimester may be a sign of psychological vulnerability or an aspect of an existing depressive state that calls for attention.