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

Diagnostic, Management, and Neonatal Outcomes of Colorectal Cancer during Pregnancy: Two Case Reports, Systematic Review of Literature and Metanalysis

OBJECTIVE

Colorectal cancer (CRC) during pregnancy is a rare occurrence, with a reported incidence of 0.8 cases per 100,000 pregnancies. Managing CRC during pregnancy poses substantial challenges for clinicians: the diagnosis is often complicated and delayed due to symptom overlap with pregnancy-related manifestations, and medical imaging is constrained by safety concerns for the foetus.

METHODS

This article presents two cases of advanced CRC diagnosed and managed during pregnancy. Additionally, we conducted a systematic review of the literature to assess diagnostic and prognostic factors involved in CRC in pregnant individuals. The systematic review, with pre-registration and approval through Prospero, involved an extensive search of medical databases (Pubmed, Web of Science, Scopus and Scholar) and statistical analysis using t-test for continuous variables and chi square for dichotomous variables.

RESULTS

A total of 1058 studies were identified. After applying exclusion criteria, sixty-six studies were included. Women whose initial symptoms were severe abdominal pain not responsive to common medical treatments and constipation (acute abdomen) had a mean gestational age at delivery lower than those who presented with paucisymptomatic onset. In our study groups, women who underwent chemotherapy during pregnancy had a higher mean gestational age at delivery and did not experience worse neonatal outcomes compared to those who did not undergo chemotherapy.

CONCLUSIONS

CRC during pregnancy poses unique diagnostic and therapeutic challenges. Collaborative efforts among various medical disciplines are essential to manage CRC during pregnancy.

Prevalence and course of pregnancy symptoms using self-reported pregnancy app symptom tracker data

During pregnancy, almost all women experience pregnancy-related symptoms. The relationship between symptoms and their association with pregnancy outcomes is not well understood. Many pregnancy apps allow pregnant women to track their symptoms. To date, the resulting data are primarily used from a commercial rather than a scientific perspective. In this work, we aim to examine symptom occurrence, course, and their correlation throughout pregnancy. Self-reported app data of a pregnancy symptom tracker is used. In this context, we present methods to handle noisy real-world app data from commercial applications to understand the trajectory of user and patient-reported data. We report real-world evidence from patient-reported outcomes that exceeds previous works: 1,549,186 tracked symptoms from 183,732 users of a smartphone pregnancy app symptom tracker are analyzed. The majority of users track symptoms on a single day. These data are generalizable to those users who use the tracker for at least 5 months. Week-by-week symptom report data are presented for each symptom. There are few or conflicting reports in the literature on the course of diarrhea, fatigue, headache, heartburn, and sleep problems. A peak in fatigue in the first trimester, a peak in headache reports around gestation week 15, and a steady increase in the reports of sleeping difficulty throughout pregnancy are found. Our work highlights the potential of secondary use of industry data. It reveals and clarifies several previously unknown or disputed symptom trajectories and relationships. Collaboration between academia and industry can help generate new scientific knowledge.

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 predictive value of common symptoms in early pregnancy for complications later in pregnancy and at birth

INTRODUCTION

The aim was to investigate whether common pregnancy-related symptoms-nausea, vomiting, back pain, pelvic girdle pain, pelvic cavity pain, vaginal bleeding, itching of vulva, pregnancy itching, leg cramps, uterine contractions and varicose veins-in the first trimester of pregnancy add to the identification of women at high risk of future pregnancy and birth complications.

MATERIAL AND METHODS

Survey data linked to national register data. All women booking an appointment for a first prenatal visit in one of 192 randomly selected General Practices in East Denmark in the period April 2015-August 2016. The General Practices included 1491 women to this prospective study. Two outcomes, pregnancy complications and birth complications, were collected from the Danish Medical Birth Register.

RESULTS

Among the 1413 included women, 199 (14%) experienced complications in later pregnancy. The most serious complication, miscarriage, was experienced by 65 women (4.6%). Other common pregnancy complications were gestational diabetes mellitus (n = 11, 0.8%), gestational hypertension without proteinuria (n = 34, 2.4%), mild to moderate preeclampsia (n = 34, 2.4%) and gestational itching with effect on liver (n = 17, 1.2%). Women who experienced pelvic girdle pain, pelvic cavity pain or vaginal bleeding in the first trimester of pregnancy had a higher risk of pregnancy complications later on in later pregnancy. None of the other examined symptoms showed associations to pregnancy complications. No associations were found between pregnancy-related physical symptoms in first trimester and birth complications.

CONCLUSIONS

Symptoms in early pregnancy do not add much information about the risk of pregnancy or birth complications, although pain and bleeding may give reason for some concern. This is an important message to women experiencing these common symptoms and to their caregivers.

A longitudinal study exploring the evolution of pain during pregnancy and after delivery: does worry matter?

The aim of this study is to evaluate the evolution of pain through pregnancy until after delivery, as well as to explore the mediating role of pregnancy worries in this evolution of pain. We conducted a longitudinal cohort study. The convenience sample was evaluated on four separate occasions: in the first trimester of pregnancy (pain), during the third trimester (pain and worry), during labor (pain), and after birth (< 24 h; pain). The final sample included 120 pregnant women with a mean age of 31.29 years (SD = 4.9; range = [22, 42 years]). The results evidenced changes in pain over time (F = 13.31, p < .001). Pain severity increased in the third trimester compared to the first trimester (t =  - 4.60; 95% CI = [- 1.31, - 0.52]; p < .001), while pain during the third trimester and pain after delivery were comparable (t =  - 0.94; 95% CI = [- 1.02, 0.36]; p = .35). Pain during labor was uncorrelated with all other pain measures, so it was not included in the model. The results of the mediation analyses indicated a total effect of pain during pregnancy (first and third trimester) and worry on pain severity after delivery (B = 0.35; SE = 0.14; t = 2.43; 95% CI = [0.06, 0.65]; p = .017). Pregnancy worries (B = 0.14; SE = 0.07; 95% CI = [0.06, 0.29]), but not pain during the third trimester (B = 0.03; SE = 0.12; 95% CI = [- 0.17, 0.31]) mediated the relationship between pain during the first trimester and pain after delivery. These results support the need to reduce worry in pregnant mothers, especially when pain during the first trimester is high, to reduce the risk of pain after delivery.

A Review on the Vagus Nerve and Autonomic Nervous System During Fetal Development: Searching for Critical Windows

The autonomic nervous system (ANS) is one of the main biological systems that regulates the body's physiology. Autonomic nervous system regulatory capacity begins before birth as the sympathetic and parasympathetic activity contributes significantly to the fetus' development. In particular, several studies have shown how vagus nerve is involved in many vital processes during fetal, perinatal, and postnatal life: from the regulation of inflammation through the anti-inflammatory cholinergic pathway, which may affect the functioning of each organ, to the production of hormones involved in bioenergetic metabolism. In addition, the vagus nerve has been recognized as the primary afferent pathway capable of transmitting information to the brain from every organ of the body. Therefore, this hypothesis paper aims to review the development of ANS during fetal and perinatal life, focusing particularly on the vagus nerve, to identify possible "critical windows" that could impact its maturation. These "critical windows" could help clinicians know when to monitor fetuses to effectively assess the developmental status of both ANS and specifically the vagus nerve. In addition, this paper will focus on which factors-i.e., fetal characteristics and behaviors, maternal lifestyle and pathologies, placental health and dysfunction, labor, incubator conditions, and drug exposure-may have an impact on the development of the vagus during the above-mentioned "critical window" and how. This analysis could help clinicians and stakeholders define precise guidelines for improving the management of fetuses and newborns, particularly to reduce the potential adverse environmental impacts on ANS development that may lead to persistent long-term consequences. Since the development of ANS and the vagus influence have been shown to be reflected in cardiac variability, this paper will rely in particular on studies using fetal heart rate variability (fHRV) to monitor the continued growth and health of both animal and human fetuses. In fact, fHRV is a non-invasive marker whose changes have been associated with ANS development, vagal modulation, systemic and neurological inflammatory reactions, and even fetal distress during labor.

Postpartum Respiratory Distress Due to Hypertension-Related Pulmonary Edema

We present the case of a 35-year-old female who presented to the emergency department (ED) shortly after undergoing a cesarean section with dyspnea. Her vitals on admission revealed hypertension, tachypnea, bradycardia, and suboptimal oxygen saturation. Physical examination was remarkable for crackles in the lower lung fields. Laboratory results revealed elevated lactate dehydrogenase (LDH), pro-B-type natriuretic peptide (pro-BNP), and D-dimer levels. A CT angiogram showed no pulmonary emboli, and an echocardiogram revealed a normal ejection fraction and no diastolic dysfunction. A chest X-ray was significant for pulmonary edema and vascular congestion. The patient was diagnosed with respiratory distress due to pulmonary edema that was secondary to hypertension. This unusual case report seeks to highlight the idea that elevated blood pressure in postpartum women should warrant careful monitoring, as its consequential manifestations may be lethal. Additionally, pulmonary edema secondary to hypertension should be considered as a differential in either postpartum or peripartum women who present with respiratory symptoms and elevated blood pressure.

Identifying Patterns of Symptom Distress in Pregnant Women: A Pilot Study

During pregnancy, a woman's enlarged uterus and the developing fetus lead to symptom distress; in turn, physical and psychological aspects of symptom distress are often associated with adverse prenatal and birth outcomes. This study aimed to identify the trends in the trajectory of these symptoms. This longitudinal study recruited 95 pregnant women, with a mean age of 32 years, from the prenatal wards of two teaching hospitals in northern Taiwan. Symptom distress was measured by a 22-item scale related to pregnancy-induced symptoms. The follow-up measurements began during the first trimester and were taken every two to four weeks until childbirth. More than half of the pregnant women experienced symptom distress manifested in a pattern depicted to be "Decreased then Increased" (56.8%). Other noticeable patterns were "Continuously Increased" (28.4%), "Increased then Decreased" (10.5%) and "Continuously Decreased" (4.2%), respectively. It is worth noting that most pregnant women recorded a transit and increase in their symptom distress, revealed by their total scores, at the second trimester (mean 22.02 weeks) of pregnancy. The participants' major pregnancy-related distress symptoms were physical and included fatigue, frequent urination, lower back pain, and difficulty sleeping. The mean scores for individual symptoms ranged from 2.32 to 3.61 and were below the "moderately distressful" level. This study provides evidence that could be used to predict women's pregnancy-related symptom distress and help healthcare providers implement timely interventions to improve prenatal care.

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.

New persistent opioid use after acute opioid prescribing in pregnancy: a nationwide analysis

OBJECTIVE

To evaluate the association between opioid prescribing during pregnancy and new persistent opioid use in the year following delivery.

MATERIALS AND METHODS

This nationwide retrospective cohort study included patients aged 12-55 years in Optum's deidentified Clinformatics Data Mart Database who were undergoing vaginal delivery or cesarean delivery from 2008 to 2016, with continuous enrollment from 2 years before birth to 1 year postdischarge. Women were included if they were opioid naive in pregnancy (ie, did not fill an opioid prescription 2 years to 9 months before delivery) and did not undergo a procedure within the year after discharge. The exposure was filling an opioid prescription in pregnancy. The primary outcome was new persistent opioid use, defined as a pharmacy claim for ≥1 opioid prescription between 4 and 90 days postdischarge and ≥1 prescription between 91 and 365 days postdischarge. Clinical and demographic covariates were included. Analyses included descriptive statistics and multivariable logistic regression, adjusting for clinical and demographic covariates.

RESULTS

Of 158,425 childbirths identified, 101,013 (63.8%) were by vaginal delivery and 57,412 (36.2%) cesarean delivery. Among all patients, 6.0% (9429) filled an opioid prescription during pregnancy. The factors associated with filling an opioid in pregnancy were having a nondelivery procedure in pregnancy (adjusted odds ratio, 9.60; 95% confidence interval, 8.81-10.47) and having an emergency room visit during pregnancy (adjusted odds ratio, 2.48; 95% confidence interval, 2.37-2.59). Of women who received an opioid in pregnancy, 4% (379) developed new persistent opioid use. The factors most associated with new persistent opioid use were receiving an opioid prescription during pregnancy (adjusted odds ratio, 3.45; 95% confidence interval, 3.04-3.92) and filling a peripartum opioid prescription (1 week prior to 3 days postdischarge) adjusted odds ratio, 2.28, 95% confidence interval (2.02-2.57). Though having a procedure during pregnancy was associated with increased receipt of an opioid prescription, it was also associated with reduced new persistent opioid use (adjusted odds ratio, 0.72; 95% confidence interval, 0.52-0.99).

CONCLUSION

Women who receive an opioid prescription during pregnancy are more likely to experience new persistent opioid use. Maternity care providers must balance pain management in pregnancy with potential risks of opioids.