Birgit Bødker

Are some perinatal deaths in immigrant groups linked to suboptimal perinatal care services

Objective To test the hypothesis that suboptimal factors in perinatal care services resulting in perinatal deaths were more common among immigrant mothers from the Horn of Africa, when compared with Swedish mothers.

Influence of chorionicity on perinatal outcome in a large cohort of Danish twin pregnancies.

To assess outcome in twin pregnancies according to chorionicity.

Is there an association between female circumcision and perinatal death

OBJECTIVE In Sweden, a country with high standards of obstetric care, the high rate of perinatal mortality among children of immigrant women from the Horn of Africa raises the question of whether there is an association between female circumcision and perinatal death. METHOD To investigate this, we examined a cohort of 63 perinatal deaths of infants born in Sweden over the period 1990-96 to circumcised women. FINDINGS We found no evidence that female circumcision was related to perinatal death. Obstructed or prolonged labour, caused by scar tissue from circumcision, was not found to have any impact on the number of perinatal deaths. CONCLUSION The results do not support previous conclusions that genital circumcision is related to perinatal death, regardless of other circumstances, and suggest that other, suboptimal factors contribute to perinatal death among circumcised migrant women.

The FIB-PPH trial: fibrinogen concentrate as initial treatment for postpartum haemorrhage: study protocol for a randomised controlled trial

BackgroundPostpartum haemorrhage (PPH) remains a leading cause of maternal mortality worldwide. In Denmark 2% of parturients receive blood transfusion. During the course of bleeding fibrinogen (coagulation factor I) may be depleted and fall to critically low levels, impairing haemostasis and thus worsening the ongoing bleeding. A plasma level of fibrinogen below 2 g/L in the early phase of postpartum haemorrhage is associated with subsequent development of severe haemorrhage. Use of fibrinogen concentrate allows high-dose substitution without the need for blood type crossmatch. So far no publications of randomised controlled trials involving acutely bleeding patients in the obstetrical setting have been published. This trial aims to investigate if early treatment with fibrinogen concentrate reduces the need for blood transfusion in women suffering severe PPH.Methods/DesignIn this randomised placebo-controlled double-blind multicentre trial, parturients with primary PPH are eligible following vaginal delivery in case of: manual removal of placenta (blood loss ≥ 500 ml) or manual exploration of the uterus after the birth of placenta (blood loss ≥ 1000 ml). Caesarean sections are also eligible in case of perioperative blood loss ≥ 1000 ml. The exclusion criteria are known inherited haemostatic deficiencies, prepartum treatment with antithrombotics, pre-pregnancy weight <45 kg or refusal to receive blood transfusion. Following informed consent, patients are randomly allocated to either early treatment with 2 g fibrinogen concentrate or 100 ml isotonic saline (placebo). Haemostatic monitoring with standard laboratory coagulation tests and thromboelastography (TEG, functional fibrinogen and Rapid TEG) is performed during the initial 24 hours.Primary outcome is the need for blood transfusion. To investigate a 33% reduction in the need for blood transfusion, a total of 245 patients will be included. Four university-affiliated public tertiary care hospitals will include patients during a two-year period. Adverse events including thrombosis are assessed in accordance with International Conference on Harmonisation (ICH) good clinical practice (GCP).DiscussionA widespread belief in the benefits of early fibrinogen substitution in cases of PPH has led to increased off-label use. The FIB-PPH trial is investigator-initiated and aims to provide an evidence-based platform for the recommendations of the early use of fibrinogen concentrate in PPH.Trial registrationClincialTrials.gov NCT01359878.

Maternal deaths in Denmark 2002–2006

Objective. To describe a method for identification, classification and assessment of maternal deaths in Denmark and to identify substandard care. Design. Register study and case audit based on data from the Registers of the Danish Medical Health Board, death certificates and hospital records. Setting. Denmark 2002–2006. Population. Women who died during a pregnancy or within 42 days after a pregnancy. Methods. Maternal deaths were identified by notification from maternity wards and data from the Danish National Board of Health. A national audit committee assessed hospital records of direct and indirect deaths. Main outcome measures. Maternal mortality ratio, causes of death and suboptimal care. Results. In the study period, 26 women died during pregnancy or within 42 days from direct or indirect causes, leading to a maternal mortality ratio of 8.0/100,000 live births. Causes of death were cardiac disease, thromboembolism, hypertensive disorders of pregnancy, Streptococcus A infections, suicide, amniotic fluid embolism, cerebrovascular hemorrhage, asthma and diabetes. Conclusion. Our method proved valid and can be used for future research. Causes of death could be identified and learning points from the assessments could form the basis of focused education and guidelines. Future complementary ‘near miss’ studies and cooperation with other countries with comparable health systems are expected to improve the benefits of the enquiries, contributing to improved management of life‐threatening conditions in pregnancy and childbirth.

Suboptimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model

BackgroundSeveral European countries report differences in risk of maternal mortality between immigrants from low- and middle-income countries and host country women. The present study identified suboptimal factors related to care-seeking, accessibility, and quality of care for maternal deaths that occurred in Sweden from 1988–2010.MethodsA subset of maternal death records (n = 75) among foreign-born women from low- and middle-income countries and Swedish-born women were audited using structured implicit review. One case of foreign-born maternal death was matched with two native born Swedish cases of maternal death. An assessment protocol was developed that applied both the ‘migration three delays’ framework and a modified version of the Confidential Enquiry from the United Kingdom. The main outcomes were major and minor suboptimal factors associated with maternal death in this high-income, low-maternal mortality context.ResultsMajor and minor suboptimal factors were associated with a majority of maternal deaths and significantly more often to foreign-born women (p = 0.01). The main delays to care-seeking were non-compliance among foreign-born women and communication barriers, such as incongruent language and suboptimal interpreter system or usage. Inadequate care occurred more often among the foreign-born (p = 0.04), whereas delays in consultation/referral and miscommunication between health care providers where equally common between the two groups.ConclusionsSuboptimal care factors, major and minor, were present in more than 2/3 of maternal deaths in this high-income setting. Those related to migration were associated to miscommunication, lack of professional interpreters, and limited knowledge about rare diseases and pregnancy complications. Increased insight into a migration perspective is advocated for maternity clinicians who provide care to foreign-born women.

Increased concentration of circulating atrial natriuretic peptide during normal pregnancy

Atrial natriuretic peptide (ANP) is a recently discovered cardiac hormone involved in blood-volume homeostasis. Known stimulating factors for ANP release are rise in atrial pressures or atrial distension, suggesting that blood volume regulates ANP release. This study was undertaken to test the hypothesis that plasma levels of ANP are high and increase during normal pregnancy secondary to the expanding plasma volume. In a cross-sectional study plasma concentrations of ANP were measured in 99 normal pregnant women at different gestational ages and compared with the values found in an age-matched non-pregnant control group. Mean plasma ANP was already significantly increased in the first trimester as opposed to the non-pregnant women, but despite a continuously expanded plasma volume there was no further increase during pregnancy. Our findings suggest that other factors must interact with plasma volume in regulating plasma ANP during pregnancy.

Cytokines and the risk of preterm delivery in twin pregnancies.

OBJECTIVE: To estimate the association between cytokine levels in twin pregnancies and risk of spontaneous preterm delivery, including the effect of progesterone treatment. METHODS: This secondary analysis of a randomized placebo-controlled trial investigating the effect of progesterone treatment on preterm delivery in twin pregnancies included 523 women with available dried blood spot samples collected before treatment with progesterone (n=258) or placebo (n=265) and after 4–8 weeks of treatment. Samples were analyzed for cytokines using a sandwich immunoassay. Cytokine levels in spontaneous preterm delivery at 34–37 weeks of gestation and spontaneous preterm delivery before 34 weeks of gestation were compared with delivery at 37 weeks of gestation or more for placebo-treated women. The association between interleukin (IL)-8 and risk of spontaneous preterm delivery before 34 weeks of gestation was estimated further, including comparison according to treatment. Statistical analyses included Kruskal-Wallis test, Mann-Whitney U test, linear regression, and Cox regression analysis. RESULTS: We found a statistically significant association between IL-8 and spontaneous preterm delivery. At 23–33 weeks of gestation, the median IL-8 level was 52 pg/mL (interquartile range 39–71, range 19–1,061) for term deliveries compared with 65 pg/mL (interquartile range 43–88, range 14–584) for spontaneous preterm delivery at 34–37 weeks of gestation and 75 pg/mL (interquartile range 57–102, range 22–1,715) for spontaneous preterm delivery before 34 weeks of gestation (P<.001). Risk of spontaneous preterm delivery was associated with a large weekly increase in IL-8 (hazard ratio 2.0, 95% confidence interval [CI] 1.2–3.3). There was no effect of progesterone treatment on IL-8 levels. Levels of IL-8 at 18–24 weeks of gestation were associated with a cervix less than 30 mm (odds ratio 1.8, 95% CI 1.2–2.7). CONCLUSION: Risk of spontaneous preterm delivery before 34 weeks of gestation is increased in women with high IL-8 levels. Progesterone treatment does not affect IL-8 levels. CLINICAL TRIAL REGISTRATION: EudraCT, https://eudract.ema.europa.eu, 2006-000503-41, and ClinicalTrials.gov, www.clinicaltrials.gov, NCT00329914. LEVEL OF EVIDENCE: II

Maternal mortality in Denmark, 1985–1994

OBJECTIVES In Denmark, maternal mortality has been reported over the last century, both locally through hospital reports and in national registries. The purpose of this study was to analyze data from national medical registries of pregnancy-related deaths in Denmark 1985-1994 and to classify them according to the UK Confidential Enquiry into Maternal Deaths (CEMD). STUDY DESIGN All deaths of women with a registered pregnancy within 12 months prior to the death were identified by comparing the Danish medical registries, death certificates, and relevant codes according to International Classification of Diseases (ICD-10). All cases were classified using the UK CEMD classification. Cases of maternal death were further evaluated by an audit group. RESULTS 311 cases were classified. 92 deaths (29.6%) occurred <or= 42 days after termination of pregnancy. Of these, 30 were classified as direct obstetric deaths, 30 as indirect obstetric deaths, and 32 as fortuitous deaths. Among the late pregnancy-related deaths (>42 days), 1 woman died from a direct obstetric cause, 46 from indirect causes, and 172 from fortuitous causes. Hypertensive disorders of pregnancy were the major cause of direct maternal deaths. The rate of maternal deaths constituted 9.8/100,000 maternities (i.e. the number of women delivering registrable live births at any gestation or stillbirths at 24 weeks of gestation or later). CONCLUSION This is the first systematic report on deaths in Denmark based on data from national registries. The maternal mortality rate in Denmark is comparable to the rates in other developed countries. Fortunately, statistics are low, but each case represents potential learning. Obstetric care has changed and classification methods differ between countries. Prospective registration and registry linkage seem to be a way to ensure completion. This retrospective study has provided the background for a prospective study on registration and evaluation of maternal mortality in Denmark.

Postpartum hematoma and vaginal packing with a blood pressure cuff

The formation of a postpartum hematoma is an uncommon but serious complication after delivery. The reported frequency of hematomas after delivery varies widely (1–3). A postpartum hematoma may be potentially lethal, if the hemodynamic status and cardiovascular stability is threatened. There are various methods for the treatment of postpartum hematomas including observation, surgical evacuation, drainage, and ligation of bleeding vessels and gauze packing of the vagina (1–5). Rectal tamponade, hysterectomy, and internal iliac artery ligation are less common (9). Angiographic embolization of bleeding sites is the newest technique described (10, 11). The purpose of this report is to describe two cases of life-threatening puerperal hematoma treated by vaginal packing with a blood pressure cuff.