Hans Wessel

Maternal risk factors for preterm birth and low birthweight in Cape Verde

Background. Fifteen years after the implementation of an antenatal risk screening program in Cape Verde, the first assessment of an association between maternal obstetric characteristics and preterm birth or low birthweight (LBW) infants was undertaken.

Deaths Among Women of Reproductive Age in Cape Verde: Causes and Avoidability

SUBJECT In 1992-93 all deaths (n=97) of women 15 to 49 years old in three islands of Cape Verde were investigated to determine the cause of death, the maternal mortality ratio, the reliability of cause-of-death ascertainment, and the level of avoidability. METHOD Data were obtained through interviews with the deceased persons family members and other knowledgeable persons (verbal autopsy) and through hospital files. RESULTS The overall mortality rate was 163 per 100,000 women 1549 years old, and the maternal mortality ratio was 127 per 100,000 live births. A plausible diagnosis could be determined in 77%. The most frequent causes of death were circulatory disorders, external causes, maternal causes, infectious diseases. and neoplasms. CONCLUSIONS It was estimated that three of four of the deaths were avoidable with locally available resources. Since access to health care in the study area is not a major hindrance, a further decrease of female mortality depends mainly on improved quality of care in health facilities.

Pregnant women’s perspectives on decision-making when a fetal malformation is detected by ultrasound examination

OBJECTIVES The aims of the study were to explore factors influencing the decision to continue or terminate pregnancy due to detection of fetal malformation following ultrasound examination, to elucidate the need for more information or other routines to facilitate the decision-making process and to assess satisfaction with the decision made. DESIGN Descriptive study. SETTING Four fetal care referral centres in Stockholm, Sweden. POPULATION Pregnant women with a detected fetal malformation. METHODS Data was collected by questionnaires. 134 women participated, 99 completing the questionnaire. Descriptive statistical analysis was performed. RESULTS Both women who continued and those who terminated pregnancy based their decision on the severity of the malformation. Other reasons for terminating the pregnancy were aspects including socioeconomic considerations. None stated religious factors. The doctor at the fetal care unit also had an influence on the decision-making. The timeframe receiving information was regarded as long enough in duration but not the number of occasions. In both groups the women made the decision by themselves or together with their partners. The majority experienced that they had made the right decision. Women who terminated their pregnancy had a significant higher rate (51.2%) (p < or = 0.004) of previous abortions than those in the continuing group (23.2%). CONCLUSION The decision to continue or terminate the pregnancy was to a great extent based on the severity of the malformation. Religious aspects did not seem to influence the decision. Many women expressed a need for additional occasion of information. The vast majority of women were satisfied with their decision.

Pregnancy termination due to fetal anomaly: Women's reactions, satisfaction and experiences of care

OBJECTIVE to explore what women who have had a pregnancy terminated due to a detected fetal malformation perceived as having been important in their encounters with caregivers for promoting their healthy adjustment and well-being. METHOD an exploratory descriptive design was used. Semi-structured interviews were audiotaped, and the information pathway described. The text was processed through qualitative content analysis in six steps. SETTING four fetal care referral centres in Stockholm, Sweden. PARTICIPANTS 11 women opting for pregnancy termination due to fetal malformation. FINDINGS in-depth understanding and compassion are important factors in providing the feeling of support people need so they are able to adapt to crisis. The women emphasised that the caregivers have to communicate a sense of responsibility, hope and respect and provide on-going care for them to feel assured of receiving good medical care and treatment. Aside from existing psychological conditions, the women identified as having emotional distress directly after termination and for at least the following three months. Most women experienced a range of negative emotions after pregnancy termination, including sadness, meaninglessness, loneliness, tiredness, grief, anger and frustration. Still some of this group had positive reactions because they experienced empathy and well-organised care. CONCLUSION AND IMPLICATIONS FOR PRACTICE The most important factors associated with satisfaction regarding pregnancy termination due to a fetal malformation are the human aspects of care, namely state-dependent communication and in-depth understanding and compassion. The changes in care most often asked for were improvements in the level of standards and provision of adequate support through state-dependent communication, in-depth understanding and compassion, and complete follow-up routines and increased resources. Targeted education for the caregivers may be suited to ensuring that they properly meet needs of their patients.

Novel topical formulation of lidocaine provides significant pain relief for intrauterine device insertion: pharmacokinetic evaluation and randomized placebo-controlled trial

OBJECTIVE To investigate the pharmacokinetics, safety, and analgesic efficacy of a novel topical formulation of lidocaine at insertion of an intrauterine device (IUD). DESIGN Randomized controlled trial; phase-I and phase-II studies. SETTING University and public hospitals. PATIENT(S) Women aged ≥18 years who wanted to receive an IUD. Four women were parous in phase I; all in phase II were nulliparous. INTERVENTION(S) A single, 8.5-mL dose of lidocaine formulation (SHACT) was administered (to the portio, cervix, and uterus) with a specially designed applicator. MAIN OUTCOME MEASURE(S) The phase-I study (single-arm) was designed for pharmacokinetic assessment; the phase-II study (randomized) was intended for investigation of efficacy and safety. RESULT(S) From the phase-I study (15 participants), mean pharmacokinetic values were: maximum plasma concentration: 351 ± 205 ng/mL; time taken to reach maximum concentration: 68 ± 41 minutes; and area under the concentration-time curve from 0 to 180 minutes: 717 ± 421 ng*h/mL. Pain relief was observed with lidocaine vs. placebo in the phase-II study (218 women, randomized). Mean visual analog scale score for maximum pain during the first 10 minutes after IUD insertion was 36% lower with lidocaine than with placebo (28.3 ± 24.6 vs. 44.2 ± 26.0). Pain intensity was also significantly lower in the lidocaine group at 30 minutes. On average, 3 of 4 patients will have less pain with lidocaine than with placebo. Adverse events were similar in the placebo and lidocaine groups. No serious adverse events were reported. CONCLUSION(S) Lidocaine provides pain relief lasting for 30-60 minutes for women undergoing IUD insertion, without any safety concerns. Further studies of this lidocaine formulation, for IUD insertion and other clinical applications, are planned. CLINICAL TRIAL REGISTRATION NUMBER 2011-005660-18 and 2011-006220-20 (EudraCT).

Lower accuracy in prediction of delivery date in Stockholm County following introduction of new guidelines

In Stockholm County, new guidelines for predicting the day of delivery were introduced in 2010. Recent clinical use has indicated that the predictive quality might be suboptimal. This study compares the accuracy of three equations applied during the first (crown–rump length or bi‐parietal diameter) and second trimesters (bi‐parietal diameter or bi‐parietal diameter combined with femur length).

Maternal emotional wellbeing over time and attachment to the fetus when a malformation is detected.

OBJECTIVES To explore womens emotional wellbeing and attachment to the fetus when informed during pregnancy of a fetal malformation. METHODS In a longitudinal community-based study, 56 pregnant women with a detected fetal malformation and continued pregnancy were invited to complete questionnaires in mid-pregnancy, two months postpartum and one year postpartum. The questionnaire included the Edinburgh Postnatal Depression Scale, the Cambridge Worry Scale, the State-Trait Anxiety Inventory, and the Maternal-Fetal Attachment Scale. Socio-demographics and obstetric background data were also collected. Descriptive statistical analyses were performed. RESULTS Approximately 84% returned the questionnaires and 37% of women in mid-pregnancy, 26.5% two months postpartum and 22% one year postpartum were found to have depressive symptoms. In mid-pregnancy 8.9% had thoughts of harming themselves, and almost all reported at least one major worry. Worry about the relationship with their husband or partner increased two months postpartum and one year postpartum. The means of both state and trait anxiety levels were high on all three measuring occasions and the mean score for maternal-fetal attachment was 3.7 (SD 0.67), indicating a high level of attachment. CONCLUSION The results highlight the importance of adequate support when fetal malformations are detected on ultrasound examination.

Pregnant women's perspectives on decision-making when a fetal malformation is detected by ultrasound examination

Objectives: Exploring factors influencing the decision to continue or terminate a pregnancy after detection of a fetal malformation following an ultrasound examination, to elucidate the need for more information or other routines to facilitate the decisionmaking process and to assess satisfaction with the decision made; Design: Descriptive study; Setting: Four fetal care referral centres in Stockholm, Sweden; Population: Pregnant women with a detected fetal malformation. Methods: Data was collected by questionnaires. 134 women participated, 99 completing the questionnaire. Descriptive statistical analysis was performed. Results: Women who continued as well as those who terminated their pregnancies based their decision on the severity of the malformation. Other reasons for terminating the pregnancy were other aspects. None stated religious factors. The doctor at the fetal care unit also had an influence on the decision-making. The timeframe receiving information was regarded as long enough in duration but not the number of occasions. In both groups the women made the decision by themselves or together with their partners. The majority experienced that they had made the right decision. Women who terminated their pregnancy had a significant higher rate (51.2%) (P = <0.004) of previous abortions than those in the continuing group (23.2%). Conclusions: All women whose fetuses had a severe malformation terminated the pregnancy. Nobody stated religious factors as a reason to terminate. Most of the women declared that they made the right decision about continuing or terminating the pregnancy. Many women expressed a need for further information on several occasions to facilitate the difficult decision-making process.