Anna Berglund

Thyroid Testing and Management of Hypothyroidism During Pregnancy: A Population-based Study

CONTEXT There are international guidelines on thyroid function testing and management of hypothyroidism during pregnancy. Few studies have evaluated how they are implemented into clinical practice. OBJECTIVE In this descriptive study, we assessed the implementation of international guidelines in this field into local guidelines and also into clinical practice. DESIGN AND PARTICIPANTS In a nationwide survey, all guidelines in Sweden were collected (n = 29), and the adherence of the local guidelines to The Endocrine Society Guidelines 2007 was evaluated. In a follow-up in 1 district, 5254 pregnant women with an estimated date of delivery between January 1, 2009, and December 31, 2011, were included for subsequent review of their medical reports. RESULTS All but 1 district had guidelines on the subject. All local guidelines included fewer than the 10 listed reasons for thyroid testing recommended by The Endocrine Society Guidelines. Furthermore, most guidelines recommended additional types of thyroid function tests to TSH sampling and lower trimester-specific TSH upper reference limits for women on levothyroxine treatment (P < .001). In the follow-up, the thyroid testing rate was 20%, with an overall frequency of women with trimester-specific elevated TSH of 18.5%. More than half of the women (50.9%) who were on levothyroxine treatment at conception had an elevated TSH level at thyroid testing according to The Endocrine Society Guidelines. CONCLUSIONS The local guidelines are variable and poorly compliant with international guidelines. Performance of thyroid testing is not optimal, and rates of elevated TSH at testing are extremely high in subgroups.

Health services effects of a reduced routine programme for antenatal care. An area-based study.

OBJECTIVE To assess the consequences of a reduction of the routine programme for surveillance of normal pregnancy. STUDY DESIGN An area-based study of a total pregnant population comparing utilization of care the years before and after a new routine antenatal programme was introduced, a reduction of three to four midwife visits during the second half of pregnancy. All women from the catchment area who gave birth in 1990 (n=2008) and 1992 (n=1874) and had attended antenatal care in the area during the second half of their pregnancy, were analyzed for use of prenatal primary and secondary care, obstetric interventions, pregnancy outcome and perinatal outcome. RESULT Compliance to the programme improved, resulting in a reduction of only 1.8 visits per pregnancy. Extra visits initiated by staff increased slightly, but extra contacts initiated by the mother remained very few. There were no significant differences in maternal outcome or obstetric interventions and the rates of prematurity, low birthweight, low Apgar score and the need for neonatal interventions were equal both years. CONCLUSION This reduction of three to four scheduled visits in the traditional antenatal care programme can be done without increasing demands for extra visits, need for specialist consultations or emergencies or less favourable outcome.

Pregnancy planning in Sweden : a pilot study among 270 women attending antenatal clinics

Objective. Health status and lifestyle before and at the time of conception could affect the health of both mother and child, but there is a lack of knowledge about the degree to which pregnancies are planned. The aim of this pilot study was to investigate whether and how women plan their pregnancies. Material and methods. The main outcome measures were use of timetables, ovulation tests and lifestyle changes. Women (n= 322) visiting four antenatal clinics were asked to fill out a questionnaire (participation rate = 83.9%, n= 270). Results. Three of four pregnancies (n= 202) were very or rather well planned, whereas 4.4% (n= 12) were totally unplanned. During the planning period, 37.1% (n= 100) made up a timetable for getting pregnant, 23% (n= 62) used ovulation tests, 20.7% (n= 56) took folic acid and 10.4% (n= 28) changed alcohol consumption. Conclusion. Although a majority of these women had planned pregnancies, only one in five had taken folic acid during the planning period.

The usefulness of initial risk assessment as a predictor of pregnancy complications and premature delivery.

BACKGROUND Risk assessment is an essential component of all programs for surveillance of pregnancy. The objective of the study is to assess the usefulness of initial risk status as predictor for pregnancy complications and premature delivery. METHODS A retrospective, area-based study including all women giving birth at Västerås Central Hospital, Sweden in 1990 (2,008) and 1992 (1,874). Data was collected before and after the introduction of a reduced routine surveillance program. The study populations were classified in a low-risk group and three risk groups according to presence of risk factors at booking (initial risk factors), development of pregnancy complications (later risk factors) or a combination of both. Relative risk for premature delivery and predictive value of initial risk factors for pregnancy complications were analyzed. RESULTS The relative risk for premature delivery was significantly increased in all three risk categories both years except for the group with only initial risk factors in 1990. Risk factors were present at booking in 27% (1990) and 26% (1992). Pregnancy complications developed in 35% and 28%, respectively. The positive predictive value of initial risk factors for pregnancy complications was 40% and 33%, adding little useful information. CONCLUSION The relative risk for premature delivery was correlated to obstetric risk but was moderately increased with initial risk factors only. The initial risk status is a poor predictor of pregnancy complications and cannot alone be used for individual planning of surveillance during pregnancy. Even for low risk women routine programs must be structured to secure adequate identification of current complications.

Successful implementation of evidence-based routines in Ukrainian maternities

Objective. To describe the process of change and assess compliance and effect on maternal and infant outcome when the WHO package Effective Perinatal Care (EPC) was implemented at maternities in Ukraine. Design. Intervention study comparing outcomes before and during 2.5 years after training. Setting. Three maternities in Donetsk, Lutsk and Lviv 2003–2006. Population. Baseline data were collected for 652, 742 and 302 deliveries and 420, 381 and 135 infants, respectively, in Donetsk, Lutsk and Lviv. Follow‐up data included 4,561, 9,865 and 7,227 deliveries and 3,829, 8,658 and 6,401 infants. Methods. Staff training on evidence‐based guideline. Main outcome measures. Interventions during labor, maternal outcomes and hypothermia in the infants. Results: EPC procedures were successfully implemented and adherence to the protocols was excellent. For most variables, the change occurred during the first three months but was well sustained. The use of partogram increased fourfold in Donetsk and from 0% to 60% in Lviv. Induction and augmentation of labor decreased to less than 1% and less than 5%, respectively. Cesarean section rate dropped significantly in two of the maternities. The proportion of hypothermic infants decreased from 60% (Donetsk), 85% (Lutsk) and 77% (Lviv) to 1% in all three maternities during the first three months and was stable throughout the study period. Admission to Neonatal Intensive Care Unit decreased significantly in two of the maternities and there was no effect on early neonatal mortality. Conclusions: The process of education and change was well anchored in the organization, and implementation of new procedures was quick and successful.

Is pregnancy planning associated with background characteristics and pregnancy‐planning behavior?

Prevalence of planned pregnancies varies between countries but is often measured in a dichotomous manner. The aim of this study was to investigate to what level pregnant women had planned their pregnancies and whether pregnancy planning was associated with background characteristics and pregnancy‐planning behavior.

Risk assessment at the end of pregnancy is a poor predictor for complications at delivery.

Objective. To evaluate the usefulness of prenatal risk assessment for prediction of need for obstetric interventions.

Adverse childhood experiences influence development of pain during pregnancy

To investigate the association between adverse childhood experiences (ACE) and pain with onset during pregnancy.

Do subfertile women adjust their habits when trying to conceive

Abstract Aim: The aim of this study was to investigate lifestyle habits and lifestyle adjustments among subfertile women trying to conceive. Materials and methods: Women (n = 747) were recruited consecutively at their first visit to fertility clinics in mid-Sweden. Participants completed a questionnaire. Data were analyzed using logistic regression, t tests, and chi-square tests. Results: The response rate was 62% (n = 466). Mean duration of infertility was 1.9 years. During this time 13.2% used tobacco daily, 13.6% drank more than three cups of coffee per day, and 11.6% consumed more than two glasses of alcohol weekly. In this sample, 23.9% of the women were overweight (body mass index, BMI 25–29.9 kg/m2), and 12.5% were obese (BMI ≥30 kg/m2). Obese women exercised more and changed to healthy diets more frequently than normal-weight women (odds ratio 7.43; 95% confidence interval 3.7–14.9). Six out of ten women (n = 266) took folic acid when they started trying to conceive, but 11% stopped taking folic acid after some time. Taking folic acid was associated with a higher level of education (p < 0.001). Conclusions: Among subfertile women, one-third were overweight or obese, and some had other lifestyle factors with known adverse effects on fertility such as use of tobacco. Overweight and obese women adjusted their habits but did not reduce their body mass index. Women of fertile age would benefit from preconception counseling, and the treatment of infertility should routinely offer interventions for lifestyle changes.

Combining the perspectives of midwives and doctors improves risk assessment in early pregnancy.

Background. Traditionally, risk identification in early pregnancy in Swedish antenatal care [ANC] is performed by the midwife at booking, and confirmed by the doctor at a routine visit in early pregnancy, but this extra visit has been questioned. This study compared the risk assessment by the two professions. Methods. In a cluster randomised trial, a planning conference, where midwives reported new mothers to a doctor, replaced the routine consultation with the doctor. Ten ANC‐clinics with the new program (942 mothers) were compared to 10 clinics with standard care (758 mothers). Risk factors were registered independently by midwives and doctors. Degree of agreement in risk identification between midwives and doctors was estimated by the kappa coefficient. Results. The degree of agreement in risk registration was good for previous pregnancy complications (κ = 0.62; CI: 0.55–0.68), and recommendations for doctors consultation (κ = 0.67; CI: 0.62–0.72); fair for social problems (κ = 0.29; CI: 0.03–0.55), and poor for registration of symptoms and problems in index pregnancy (κ = 0.09; CI: 0.03–0.21) and psychosocial aspects, such as anxiety (κ = 0.09; CI: 0.03–0.21). Significantly more risk factors were registered in the study group. Conclusions: Replacing the routine consultation with the doctor early in pregnancy with a planning conference had no negative impact on risk identification. The results support that the different perspectives of the two professions in combination are important for the safety of surveillance and the psychosocial support expected from antenatal care.