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Mårild K, Söderling J, Stephansson O, Axelrad J, Halfvarson J, Bröms G, Marsal J, Olén O, Ludvigsson JF. Histologic Remission in Inflammatory Bowel Disease and Female Fertility: A Nationwide Study. Gastroenterology 2024; 166:802-814.e18. [PMID: 38331202 DOI: 10.1053/j.gastro.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 01/04/2024] [Accepted: 01/13/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND & AIMS Inflammatory bowel disease (IBD) is linked to reduced female fertility, but it is unclear how fertility rates vary by histologic disease activity. METHODS Nationwide IBD cohort of Swedish women aged 15 to 44 years. We examined fertility rates during periods with vs without histologic inflammation (n = 21,046; follow-up, 1990-2016) and during periods with vs without clinical activity (IBD-related hospitalization, surgery, or treatment escalation) (n = 24,995; follow-up, 2006-2020). Accounting for sociodemographics and comorbidities, we used Poisson regression to estimate adjusted fertility rate ratios (aFRRs) for live births conceived during 12-month periods of histologic inflammation (vs histologic remission) and 3-month periods of clinically active IBD (vs quiescent IBD). RESULTS During periods with vs without histologic inflammation, there were 6.35 (95% confidence interval [CI], 5.98-6.73) and 7.09 (95% CI, 6.48-7.70) live births conceived per 100 person-years of follow-up, respectively, or 1 fewer child per 14 women with 10 years of histologic inflammation (aFRR, 0.90; 95% CI, 0.81-1.00). In women with histologic inflammation, fertility was similarly reduced in ulcerative colitis (UC) (aFRR, 0.89 [95% CI, 0.78-1.02]) and Crohn's disease (CD) (aFRR, 0.86 [95% CI, 0.72-1.04]). Clinical IBD activity was associated with an aFRR of 0.76 (95% CI, 0.72-0.79) or 1 fewer child per 6 women with 10 years of clinical activity. Fertility was reduced in clinically active UC (aFRR, 0.75 [95% CI, 0.70-0.81]) and CD (aFRR, 0.76 [95% CI, 0.70-0.82]). Finally, among women with clinically quiescent IBD, histologic inflammation (vs histologic remission) was associated with reduced fertility (aFRR, 0.85 [95% CI, 0.73-0.98]). CONCLUSIONS An association between histologic and clinical activity and reduced female fertility in CD and UC was found. Notably, histologic inflammation was also linked to reduced fertility in women with clinically quiescent IBD.
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Affiliation(s)
- Karl Mårild
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden; Department of Pediatrics, Queen Silvia Children's Hospital, Gothenburg, Sweden.
| | - Jonas Söderling
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden; Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jordan Axelrad
- Inflammatory Bowel Disease Center at NYU Langone Health, Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Gabriella Bröms
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Gastroenterology, Danderyd Hospital, Stockholm, Sweden
| | - Jan Marsal
- Department of Gastroenterology, Skåne University Hospital, Lund, Sweden; Immunology Section, Lund University, Lund, Sweden
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden; Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
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Kogner L, Lundborg L, Liu X, Ladfors LV, Ahlberg M, Stephansson O, Sandström A. Duration of the active first stage of labour and severe perineal lacerations and maternal postpartum complications: a population-based cohort study. BJOG 2024; 131:832-842. [PMID: 37840230 DOI: 10.1111/1471-0528.17692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVE The impact of first stage labour duration on maternal outcomes is sparsely investigated. We aimed to study the association between a longer active first stage and maternal complications in the early postpartum period. DESIGN A population-based cohort study. SETTING Regions of Stockholm and Gotland, Sweden, 2008-2020. POPULATION A cohort of 159 459 term, singleton, vertex pregnancies, stratified by parity groups. METHODS The exposure was active first stage duration, categorised in percentiles. Poisson regression analysis was performed to estimate the adjusted relative risk (aRR) and the 95% confidence interval (95% CI). To investigate the effect of second stage duration on the outcome, mediation analysis was performed. MAIN OUTCOME MEASURES Severe perineal lacerations (third or fourth degree), postpartum infection, urinary retention and haematoma in the birth canal or ruptured sutures. RESULTS The risks of severe perineal laceration, postpartum infection and urinary retention increased with a longer active first stage, both overall and stratified by parity group. The aRR increased with a longer active first stage, using duration of <50th percentile as the reference. In the ≥90th percentile category, the aRR for postpartum infection was 1.64 (95% CI 1.46-1.84) in primiparous women, 2.43 (95% CI 1.98-2.98) in parous women with no previous caesarean delivery (CD) and 2.33 (95% CI 1.65-3.28) in parous women with a previous CD. The proportion mediated by second stage duration was 33.4% to 36.9% for the different outcomes in primiparous women. The risk of haematoma or ruptured sutures did not increased with a longer active first stage. CONCLUSIONS Increasing active first stage duration is associated with maternal complications in the early postpartum period.
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Affiliation(s)
- Lisa Kogner
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Louise Lundborg
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Xingrong Liu
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Linnea V Ladfors
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Mia Ahlberg
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Sandström
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
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Magnus MC, Rasmussen TD, Örtqvist AK, Oakley LL, Urhoj SK, Stephansson O, Håberg SE. Covid-19 vaccination during pregnancy is not associated with an increased risk of severe post-partum hemorrhage. Am J Obstet Gynecol 2024:S0002-9378(24)00554-4. [PMID: 38697336 DOI: 10.1016/j.ajog.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/04/2024]
Affiliation(s)
- Maria C Magnus
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway.
| | | | - Anne K Örtqvist
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynaecology, Visby County Hospital, Visby, Sweden
| | - Laura L Oakley
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway; Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stine Kjaer Urhoj
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Department of Women's Health, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Siri E Håberg
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Johansson K, Bodnar LM, Stephansson O, Abrams B, Hutcheon JA. Safety of low weight gain or weight loss in pregnancies with class 1, 2, and 3 obesity: a population-based cohort study. Lancet 2024; 403:1472-1481. [PMID: 38555927 DOI: 10.1016/s0140-6736(24)00255-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/24/2024] [Accepted: 02/07/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND There are concerns that current gestational weight gain recommendations for women with obesity are too high and that guidelines should differ on the basis of severity of obesity. In this study we investigated the safety of gestational weight gain below current recommendations or weight loss in pregnancies with obesity, and evaluated whether separate guidelines are needed for different obesity classes. METHODS In this population-based cohort study, we used electronic medical records from the Stockholm-Gotland Perinatal Cohort study to identify pregnancies with obesity (early pregnancy BMI before 14 weeks' gestation ≥30 kg/m2) among singleton pregnancies that delivered between Jan 1, 2008, and Dec 31, 2015. The pregnancy records were linked with Swedish national health-care register data up to Dec 31, 2019. Gestational weight gain was calculated as the last measured weight before or at delivery minus early pregnancy weight (at <14 weeks' gestation), and standardised for gestational age into z-scores. We used Poisson regression to assess the association of gestational weight gain z-score with a composite outcome of: stillbirth, infant death, large for gestational age and small for gestational age at birth, preterm birth, unplanned caesarean delivery, gestational diabetes, pre-eclampsia, excess postpartum weight retention, and new-onset longer-term maternal cardiometabolic disease after pregnancy, weighted to account for event severity. We calculated rate ratios (RRs) for our composite adverse outcome along the weight gain z-score continuum, compared with a reference of the current lower limit for gestational weight gain recommended by the US Institute of Medicine (IOM; 5 kg at term). RRs were adjusted for confounding factors (maternal age, height, parity, early pregnancy BMI, early pregnancy smoking status, prepregnancy cardiovascular disease or diabetes, education, cohabitation status, and Nordic country of birth). FINDINGS Our cohort comprised 15 760 pregnancies with obesity, followed up for a median of 7·9 years (IQR 5·8-9·4). 11 667 (74·0%) pregnancies had class 1 obesity, 3160 (20·1%) had class 2 obesity, and 933 (5·9%) had class 3 obesity. Among these pregnancies, 1623 (13·9%), 786 (24·9%), and 310 (33·2%), respectively, had weight gain during pregnancy below the lower limit of the IOM recommendation (5 kg). In pregnancies with class 1 or 2 obesity, gestational weight gain values below the lower limit of the IOM recommendation or weight loss did not increase risk of the adverse composite outcome (eg, at weight gain z-score -2·4, corresponding to 0 kg at 40 weeks: adjusted RR 0·97 [95% CI 0·89-1·06] in obesity class 1 and 0·96 [0·86-1·08] in obesity class 2). In pregnancies with class 3 obesity, weight gain values below the IOM limit or weight loss were associated with reduced risk of the adverse composite outcome (eg, adjusted RR 0·81 [0·71-0·89] at weight gain z-score -2·4, or 0 kg). INTERPRETATION Our findings support calls to lower or remove the lower limit of current IOM recommendations for pregnant women with obesity, and suggest that separate guidelines for class 3 obesity might be warranted. FUNDING Karolinska Institutet and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
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Affiliation(s)
- Kari Johansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden.
| | - Lisa M Bodnar
- Department of Epidemiology, School of Public Health and Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Barbara Abrams
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
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Ahlqvist VH, Sjöqvist H, Dalman C, Karlsson H, Stephansson O, Johansson S, Magnusson C, Gardner RM, Lee BK. Acetaminophen Use During Pregnancy and Children's Risk of Autism, ADHD, and Intellectual Disability. JAMA 2024; 331:1205-1214. [PMID: 38592388 PMCID: PMC11004836 DOI: 10.1001/jama.2024.3172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/22/2024] [Indexed: 04/10/2024]
Abstract
Importance Several studies suggest that acetaminophen (paracetamol) use during pregnancy may increase risk of neurodevelopmental disorders in children. If true, this would have substantial implications for management of pain and fever during pregnancy. Objective To examine the associations of acetaminophen use during pregnancy with children's risk of autism, attention-deficit/hyperactivity disorder (ADHD), and intellectual disability. Design, Setting, and Participants This nationwide cohort study with sibling control analysis included a population-based sample of 2 480 797 children born in 1995 to 2019 in Sweden, with follow-up through December 31, 2021. Exposure Use of acetaminophen during pregnancy prospectively recorded from antenatal and prescription records. Main Outcomes and Measures Autism, ADHD, and intellectual disability based on International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes in health registers. Results In total, 185 909 children (7.49%) were exposed to acetaminophen during pregnancy. Crude absolute risks at 10 years of age for those not exposed vs those exposed to acetaminophen were 1.33% vs 1.53% for autism, 2.46% vs 2.87% for ADHD, and 0.70% vs 0.82% for intellectual disability. In models without sibling control, ever-use vs no use of acetaminophen during pregnancy was associated with marginally increased risk of autism (hazard ratio [HR], 1.05 [95% CI, 1.02-1.08]; risk difference [RD] at 10 years of age, 0.09% [95% CI, -0.01% to 0.20%]), ADHD (HR, 1.07 [95% CI, 1.05-1.10]; RD, 0.21% [95% CI, 0.08%-0.34%]), and intellectual disability (HR, 1.05 [95% CI, 1.00-1.10]; RD, 0.04% [95% CI, -0.04% to 0.12%]). To address unobserved confounding, matched full sibling pairs were also analyzed. Sibling control analyses found no evidence that acetaminophen use during pregnancy was associated with autism (HR, 0.98 [95% CI, 0.93-1.04]; RD, 0.02% [95% CI, -0.14% to 0.18%]), ADHD (HR, 0.98 [95% CI, 0.94-1.02]; RD, -0.02% [95% CI, -0.21% to 0.15%]), or intellectual disability (HR, 1.01 [95% CI, 0.92-1.10]; RD, 0% [95% CI, -0.10% to 0.13%]). Similarly, there was no evidence of a dose-response pattern in sibling control analyses. For example, for autism, compared with no use of acetaminophen, persons with low (<25th percentile), medium (25th-75th percentile), and high (>75th percentile) mean daily acetaminophen use had HRs of 0.85, 0.96, and 0.88, respectively. Conclusions and Relevance Acetaminophen use during pregnancy was not associated with children's risk of autism, ADHD, or intellectual disability in sibling control analysis. This suggests that associations observed in other models may have been attributable to familial confounding.
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Affiliation(s)
- Viktor H. Ahlqvist
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Hugo Sjöqvist
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Christina Dalman
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Karlsson
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women’s Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Johansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatology, Sachs’ Children and Youth Hospital, Stockholm, Sweden
| | - Cecilia Magnusson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Renee M. Gardner
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Brian K. Lee
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania
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Ludvigsson JF, Håberg SE, Juliusson PB, Andersen AMN, Urhoj SK, Stephansson O. Three Scandinavian countries did not see the same increase in foetal situs inversus observed in China during the COVID-19 pandemic. Acta Paediatr 2024; 113:751-752. [PMID: 38308485 DOI: 10.1111/apa.17141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
| | - Siri Eldevik Håberg
- Centre for Fertility and Health, Norwegian Institute of Health, Oslo, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Petur B Juliusson
- Department of Health Registry Research and Development, Norwegian Institute of Health, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Stine Kjaer Urhoj
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Olof Stephansson
- Department of Medicine, Karolinska Institutet, Solna, Sweden
- Department of Women's Health and Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
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Newby-Kew A, Sandström A, Wikström AK, Stephansson O, Snowden JM. Severe Perineal Lacerations in First Delivery: Association with Subsequent Reproductive Outcomes. J Womens Health (Larchmt) 2024; 33:542-550. [PMID: 38061037 DOI: 10.1089/jwh.2023.0312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
Background: Severe perineal lacerations (SPLs), common worldwide, are associated with short- and long-term complications: pelvic floor disorders, fecal incontinence, fistula, and profound psychological impacts. Limited research suggests that experiencing SPL may influence future reproductive intentions, but research on outcomes is lacking. Methods: We analyzed the effect of experiencing SPL during a first delivery among a large cohort of Swedish births between 1992 and 2013. We used linear and multinomial logistic regression to estimate the associations between SPL and four reproductive outcomes: subsequent total birth number, probability of a second birth, interpregnancy interval (IPI), and subsequent scheduled cesarean birth. Results: Among 947,035 singleton live-born first-births, we found that experiencing SPL was associated with slightly fewer overall births in fully adjusted models (a decrease of -0.020 births; 95% confidence interval [CI]: -0.028 to -0.012), but no difference in the probability of a second birth (risk ratio [RR]: 1.00; 95% CI: 0.99 to 1.00) or IPI. Scheduled cesarean was increased in births after SPL (adjusted RR: 4.57; 95% CI: 4.42 to 4.73). A secondary comparison of SPL to severe postpartum hemorrhage suggests that some of these observed differences may be related to experiencing any severe outcome, and some specifically to perineum disruption. Conclusion: This study provides a deeper understanding of the long-term impacts of SPL, which may be useful in informing best clinical practices for supporting women who have experienced SPL.
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Affiliation(s)
- Abigail Newby-Kew
- School of Public Health, Oregon Health and Science University-Portland State University, Portland, Oregon, USA
| | - Anna Sandström
- Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Anna-Karin Wikström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Olof Stephansson
- Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Jonathan M Snowden
- School of Public Health, Oregon Health and Science University-Portland State University, Portland, Oregon, USA
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
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Norman M, Magnus MC, Söderling J, Juliusson PB, Navér L, Örtqvist AK, Håberg S, Stephansson O. Neonatal Outcomes After COVID-19 Vaccination in Pregnancy. JAMA 2024; 331:396-407. [PMID: 38319332 PMCID: PMC10848052 DOI: 10.1001/jama.2023.26945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/10/2023] [Indexed: 02/07/2024]
Abstract
Importance Better knowledge about neonatal adverse events after COVID-19 vaccination during pregnancy could help address concerns about vaccine safety. Objective To evaluate the risks of neonatal adverse events after exposure to COVID-19 vaccination during pregnancy. Design, Setting, and Participants Population-based cohort study including all infants in Sweden and Norway born from June 2021 to January 2023. Unique personal identity numbers were used to link individual information from different national registers. Exposure Administration of any mRNA vaccine against COVID-19 during pregnancy, irrespective of previous vaccination, number of doses during pregnancy, or vaccine manufacturer. Main Outcomes and Measures Outcomes were neonatal conditions with bleeding/thrombosis or inflammation/infection; disorders of the central nervous system; circulatory, respiratory, or gastrointestinal problems; and neonatal mortality. Statistical methods included logistic regression adjusted for characteristics of the pregnant individuals, with additional restricted and stratified analyses. Results Of 196 470 newborn infants included (51.3% male, 93.8% born at term, 62.5% born in Sweden), 94 303 (48.0%) were exposed to COVID-19 vaccination during pregnancy. Exposed infants exhibited no increased odds of adverse neonatal outcomes, and they exhibited lower odds for neonatal nontraumatic intracranial hemorrhage (event rate, 1.7 vs 3.2/1000; adjusted odds ratio [aOR], 0.78 [95% CI, 0.61-0.99]), hypoxic-ischemic encephalopathy (1.8 vs 2.7/1000; aOR, 0.73 [95% CI, 0.55-0.96]), and neonatal mortality (0.9 vs 1.8/1000; aOR, 0.68 [95% CI, 0.50-0.91]). Subgroup analyses found a similar association between vaccination during pregnancy and lower neonatal mortality; subgroups were restricted to infants delivered by individuals unvaccinated before pregnancy, individuals vaccinated before pregnancy, individuals vaccinated after a general recommendation of vaccination during pregnancy was issued, and individuals without COVID-19 infection during pregnancy. Analyses restricted to term infants, singleton births, or infants without birth defects yielded similar results. Stratifying the analysis by vaccine manufacturer did not attenuate the association between vaccination and low neonatal mortality. Conclusions and Relevance In this large population-based study, vaccination of pregnant individuals with mRNA COVID-19 vaccines was not associated with increased risks of neonatal adverse events in their infants.
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Affiliation(s)
- Mikael Norman
- Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Maria C. Magnus
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Jonas Söderling
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Petur B. Juliusson
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Health Registry Research and Development, Norwegian Institute of Public Health, Bergen, Norway
- Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lars Navér
- Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Anne K. Örtqvist
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Visby County Hospital, Visby, Sweden
| | - Siri Håberg
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women’s Health, Karolinska University Hospital, Stockholm, Sweden
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Mitha A, Chen R, Razaz N, Johansson S, Stephansson O, Altman M, Bolk J. Neurological development in children born moderately or late preterm: national cohort study. BMJ 2024; 384:e075630. [PMID: 38267070 DOI: 10.1136/bmj-2023-075630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
OBJECTIVE To assess long term neurodevelopmental outcomes of children born at different gestational ages, particularly 32-33 weeks (moderately preterm) and 34-36 weeks (late preterm), compared with 39-40 weeks (full term). DESIGN Nationwide cohort study. SETTING Sweden. PARTICIPANTS 1 281 690 liveborn singleton children without congenital malformations born at 32+0 to 41+6 weeks between 1998 and 2012. MAIN OUTCOME MEASURES The primary outcomes of interest were motor, cognitive, epileptic, hearing, and visual impairments and a composite of any neurodevelopmental impairment, diagnosed up to age 16 years. Hazard ratios and 95% confidence intervals were estimated using Cox regression adjusted for parental and infant characteristics in the study population and in the subset of full siblings. Risk differences were also estimated to assess the absolute risk of neurodevelopmental impairment. RESULTS During a median follow-up of 13.1 years (interquartile range 9.5-15.9 years), 75 311 (47.8 per 10 000 person years) liveborn singleton infants without congenital malformations had at least one diagnosis of any neurodevelopmental impairment: 5899 (3.6 per 10 000 person years) had motor impairment, 27 371 (17.0 per 10 000 person years) cognitive impairment, 11 870 (7.3 per 10 000 person years) epileptic impairment, 19 700 (12.2 per 10 000 person years) visual impairment, and 20 393 (12.6 per 10 000 person years) hearing impairment. Children born moderately or late preterm, compared with those born full term, showed higher risks for any impairment (hazard ratio 1.73 (95% confidence interval 1.60 to 1.87) and 1.30 (1.26 to 1.35); risk difference 4.75% (95% confidence interval 3.88% to 5.60%) and 2.03% (1.75% to 2.35%), respectively) as well as motor, cognitive, epileptic, visual, and hearing impairments. Risks for neurodevelopmental impairments appeared highest from 32 weeks (the earliest gestational age), gradually declined until 41 weeks, and were also higher at 37-38 weeks (early term) compared with 39-40 weeks. In the sibling comparison analysis (n=349 108), most associations remained stable except for gestational age and epileptic and hearing impairments, where no association was observed; for children born early term the risk was only higher for cognitive impairment compared with those born full term. CONCLUSIONS The findings of this study suggest that children born moderately or late preterm have higher risks of adverse neurodevelopmental outcomes. The risks should not be underestimated as these children comprise the largest proportion of children born preterm. The findings may help professionals and families achieve a better risk assessment and follow-up.
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Affiliation(s)
- Ayoub Mitha
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- CHU Lille, Pediatric and Neonatal Intensive Care Transport Unit, Department of Emergency Medicine, Lille, France
- Université Paris Cité, CRESS, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé) INSERM, INRAE, Paris, France
| | - Ruoqing Chen
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, 518107, China
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Neda Razaz
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Johansson
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Olof Stephansson
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Maria Altman
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Rheumatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Jenny Bolk
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
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10
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Ladfors LV, Butwick A, Stephansson O. A validation of The California Maternal Quality Care Collaborative obstetric hemorrhage risk assessment tool in a Swedish population. Am J Obstet Gynecol MFM 2024; 6:101240. [PMID: 38056628 DOI: 10.1016/j.ajogmf.2023.101240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/23/2023] [Accepted: 11/27/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Linnea V Ladfors
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Maria Aspmans gata 16, 17164 Solna, Stockholm, Sweden.
| | - Alexander Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden; Division of Obstetrics, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
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11
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Chen S, Ahlqvist VH, Sjöqvist H, Stephansson O, Magnusson C, Dalman C, Karlsson H, Lee BK, Gardner RM. Maternal intrahepatic cholestasis of pregnancy and neurodevelopmental conditions in offspring: A population-based cohort study of 2 million Swedish children. PLoS Med 2024; 21:e1004331. [PMID: 38227577 PMCID: PMC10790993 DOI: 10.1371/journal.pmed.1004331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 12/06/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is the most common obstetric liver disorder and is associated with an increased risk of iatrogenic preterm birth and adverse infant outcomes. Hence, there are several plausible pathways through which ICP could affect offspring neurodevelopment. However, to the best of our knowledge, no studies have investigated these associations. Thus, we aimed to determine whether ICP is associated with offspring neurodevelopmental conditions. METHODS AND FINDINGS In this Swedish register-based cohort study, we included singleton non-adopted children born in Sweden between the 1st of January 1987 and the 31st of December 2010, who were resident in Sweden >5 years, with no missing covariate information, which we followed until the 31st of December 2016. Maternal ICP diagnosis and the date of the initial diagnosis during pregnancy were obtained from the National Patient Register. Offspring diagnoses of attention deficit/hyperactivity disorder (ADHD), autism, or intellectual disability were obtained from the National Patient Register, and the dispensation of ADHD medications were obtained from the Prescribed Drug Register. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression while controlling for observed confounders and unobserved confounders shared among full siblings and maternal full cousins. A total of 2,375,856 children were included in the study; 81.6% of them were of Nordic origin, and 51.4% were male. Of these, 10,378 (0.44%) were exposed to ICP. During a median of 18 years follow-up (interquartile range 11 to 24), 143,746 (6.05%) of children were diagnosed with a neurodevelopmental condition. After adjusting for child's sex, birth year, birth month, maternal age, highest parental education level, maternal birth country, birth order, maternal psychiatric history, ICP was associated with increased odds of offspring neurodevelopmental conditions (OR 1.22, 95% CI 1.13 to 1.31), particularly among those exposed to early-onset ICP (OR 2.38, 95% CI 1.71 to 3.30) as compared to ICP diagnosed after reaching term (≥37 weeks of gestation) (OR 1.08, 95% CI 0.97 to 1.20). The findings of early-onset ICP were consistent in family-based analyses. Within-family comparisons of full maternal cousins yielded an OR of 2.99 (95% CI 1.48 to 6.04), and comparisons of full siblings showed an OR of 1.92 (95% CI 0.92 to 4.02), though the latter was less precise. The findings were consistent across specific neurodevelopmental conditions and different analytical approaches. The primary limitations of this study included its observational design, the absence of data on ICP therapeutics, and the lack of bile acid measures. CONCLUSIONS In this study, we observed that exposure to ICP during gestation is associated with an increased likelihood of neurodevelopmental conditions in offspring, particularly in cases of early-onset ICP. Further studies are warranted to better understand the role of early-ICP in offspring neurodevelopment.
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Affiliation(s)
- Shuyun Chen
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Viktor H. Ahlqvist
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Hugo Sjöqvist
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women’s Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Cecilia Magnusson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Christina Dalman
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Håkan Karlsson
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Brian K. Lee
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania, United States of America
- Department of Epidemiology and Biostatistics, Drexel University School of Public Health, Philadelphia, Pennsylvania, United States of America
| | - Renee M. Gardner
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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12
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Farooqi A, Hakansson S, Serenius F, Kallen K, Björklund L, Normann E, Domellöf M, Ådén U, Abrahamsson T, Elfvin A, Sävman K, Bergström PU, Stephansson O, Ley D, Hellstrom-Westas L, Norman M. One-year survival and outcomes of infants born at 22 and 23 weeks of gestation in Sweden 2004-2007, 2014-2016 and 2017-2019. Arch Dis Child Fetal Neonatal Ed 2023; 109:10-17. [PMID: 37290903 DOI: 10.1136/archdischild-2022-325164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/23/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To explore associations between perinatal activity and survival in infants born at 22 and 23 weeks of gestation in Sweden. DESIGN/SETTING Data on all births at 22 and 23 weeks' gestational age (GA) were prospectively collected in 2004-2007 (T1) or obtained from national registers in 2014-2016 (T2) and 2017-2019 (T3). Infants were assigned perinatal activity scores based on 3 key obstetric and 4 neonatal interventions. MAIN OUTCOME One-year survival and survival without major neonatal morbidities (MNM): intraventricular haemorrhage grade 3-4, cystic periventricular leucomalacia, surgical necrotising enterocolitis, retinopathy of prematurity stage 3-5 or severe bronchopulmonary dysplasia. The association of GA-specific perinatal activity score and 1-year survival was also determined. RESULTS 977 infants (567 live births and 410 stillbirths) were included: 323 born in T1, 347 in T2 and 307 in T3. Among live-born infants, survival at 22 weeks was 5/49 (10%) in T1 and rose significantly to 29/74 (39%) in T2 and 31/80 (39%) in T3. Survival was not significantly different between epochs at 23 weeks (53%, 61% and 67%). Among survivors, the proportions without MNM in T1, T2 and T3 were 20%, 17% and 19% for 22 weeks and 17%, 25% and 25% for 23 weeks' infants (p>0.05 for all comparisons). Each 5-point increment in GA-specific perinatal activity score increased the odds for survival in first 12 hours of life (adjusted OR (aOR) 1.4; 95% CI 1.3 to 1.6) in addition to 1-year survival (aOR 1.2; 95% CI 1.1 to 1.3), and among live-born infants it was associated with increased survival without MNM (aOR 1.3; 95% CI 1.1 to 1.4). CONCLUSION Increased perinatal activity was associated with reduced mortality and increased chances of survival without MNM in infants born at 22 and 23 weeks of GA.
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Affiliation(s)
- Aijaz Farooqi
- Department of Clinical Sciences, Pediatrics, Umeå University, Umea, Sweden
| | - Stellan Hakansson
- Department of Clinical Sciences, Pediatrics, Umeå University, Umea, Sweden
- Pediatrics, Swedish Neonatal Quality Register, Umeå Universitet, Umea, Sweden
| | - Fredrik Serenius
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Karin Kallen
- Department of Reproductive Epidemiology, Lund University, Lund, Sweden
| | - Lars Björklund
- Departments of Clinical Sciences and Pediatrics, Skåne University Hospital Lund, Lund, Sweden
| | - Erik Normann
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences-Pediatrics, Umeå universitet Medicinska fakulteten, Umea, Sweden
| | - Ulrika Ådén
- Woman and Child Health, Karolinska Institute, Stockholm, Sweden
| | - Thomas Abrahamsson
- Department of Biomedical and Clinical Sciences and Department of Pediatrics, Linköping University, Linkoping, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
- Department of Pediatrics, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Karin Sävman
- Department of Pediatrics, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Petra Um Bergström
- Clinical Science and Education at Sodersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Olof Stephansson
- Departments of Medicine and Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - David Ley
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
| | | | - Mikael Norman
- Neonatal Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
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13
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Ivert A, Holowko N, Liu X, Edqvist M, Roos N, Gustafson P, Stephansson O. Maternal and pregnancy predictive risk factors for having a compensated maternal injury claim: a Swedish nationwide cohort study. Sci Rep 2023; 13:21731. [PMID: 38066197 PMCID: PMC10709443 DOI: 10.1038/s41598-023-49234-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/06/2023] [Indexed: 12/18/2023] Open
Abstract
To describe trends and identify maternal and pregnancy predictive risk factors for having a compensated claim for a maternal injury during delivery, as a proxy for having received suboptimal care. This nationwide retrospective cohort study included 1 754 869 births in Sweden between 2000 and 2016, including 4488 maternal injury claims filed with The National Swedish Patient Insurance Company (Löf), of which 1637 were compensated. Descriptive statistics on maternal and pregnancy characteristics, trends in filed/compensated claims over time, and distribution of compensated claims by clinical classification are presented. Characteristics associated with suboptimal care were identified using multivariable logistic regression, with mutual adjustment in the final model. Compensated claims were sorted into 14 clinical classifications (ICD-10 codes for main condition, injury, and causality). Overall, there was a two-fold increase in filed claims from 2000 to 2016, peaking in 2014. The rate of compensated claims only increased marginally, and 36.5% of filed claims were deemed avoidable. Perineal and pelvic floor injuries, as well as medical and diagnostic errors, were responsible for the majority of compensated claims. Women with a previous caesarean section, post term delivery, chronic or gestational disease, > 13 antenatal visits, or a multiple pregnancy had increased risk of having a compensated claim for a maternal injury during delivery. Understanding the risk factors for having a compensated maternal injury claim may guide health workers and maternity wards in improving the quality and organisation of care to reduce the risk of childbirth related injuries.
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Affiliation(s)
- A Ivert
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, K2 Medicin, Solna, K2 KEP Stephansson, Solna, 171 77, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - N Holowko
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, K2 Medicin, Solna, K2 KEP Stephansson, Solna, 171 77, Stockholm, Sweden.
| | - X Liu
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, K2 Medicin, Solna, K2 KEP Stephansson, Solna, 171 77, Stockholm, Sweden
| | - M Edqvist
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, K2 Medicin, Solna, K2 KEP Stephansson, Solna, 171 77, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - N Roos
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, K2 Medicin, Solna, K2 KEP Stephansson, Solna, 171 77, Stockholm, Sweden
| | - P Gustafson
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Löf - the National Swedish Patient Insurance Company, Stockholm, Sweden
| | - O Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, K2 Medicin, Solna, K2 KEP Stephansson, Solna, 171 77, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
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14
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Sandström A, Frisell T, Stephansson O, Cnattingius S. [Swedish Medical Birth Register 50 years - a source for scientific publications]. Lakartidningen 2023; 120:23170. [PMID: 38054586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
The nationwide Swedish Medical Birth Register (MBR) includes more than 98% of all births in Sweden since 1973. The MBR is updated annually, and is based on information from antenatal, obstetric, and neonatal records. Maternal information includes self-reported medical history, socio-demographic factors, smoking and snuff use, medication use, height and measured weight. Birth and neonatal/postpartal data include birth date, mode of delivery, singleton or multiple birth, gestational age, stillbirth, birth weight, birth length, head circumference, infant sex, Apgar scores, and maternal and infant diagnoses/procedures. The overall quality of the MBR is very high, partly due to the semi-automated data extraction from the standardized regional electronic health records. The MBR can be linked to other health registers through the unique personal identity numbers of mothers and live-born offspring. More than 1000 scientific publications have used MBR as a data source.
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Affiliation(s)
- Anna Sandström
- docent, biträdande överläkare, ME graviditet och förlossning, Karolinska universitetssjukhuset Solna
| | - Thomas Frisell
- docent, avdelningen för klinisk epidemiologi, institutionen för medi-cin Solna, Karolinska institutet, Solna
| | - Olof Stephansson
- professor, överläkare, avdelningen för klinisk epidemiologi, institutionen för medi-cin Solna, Karolinska institutet, Solna
| | - Sven Cnattingius
- professor, avdelningen för klinisk epidemiologi, institutionen för medicin Solna, Karolinska institutet, Solna
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15
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Röjler L, Uchida AM, Garber JJ, Stephansson O, Söderling J, Roelstraete B, Ludvigsson JF. Pregnancy Outcomes in Females with Eosinophilic Esophagitis: A Nationwide Population-Based Study. Inflamm Intest Dis 2023; 8:143-152. [PMID: 38115912 PMCID: PMC10727518 DOI: 10.1159/000534412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 09/27/2023] [Indexed: 12/21/2023] Open
Abstract
Introduction Eosinophilic esophagitis (EoE) is a chronic, allergic inflammatory disease of the esophagus. It has a peak incidence in the 2nd and 3rd decades of life. Despite this, little is known about pregnancy outcomes in patients with EoE. Methods Using a validated histopathologic and nationwide population-based cohort for the diagnosis of EoE, we examined maternal and fetal outcomes, with preterm birth as the primary outcome, in females with EoE compared to matched controls. Odds ratios (ORs) were calculated using logistic regression. Results Between 1992 and 2016, we identified 19 females with EoE who gave birth to 23 children (reference births: n = 115). There was 1 (4.3%) preterm birth in the EoE cohort versus 8 (7.0%) in the reference cohort (OR = 0.60; 95% CI = 0.07-5.14). Secondary fetal outcomes included stillbirth, neonatal death, small for gestational age, low birth weight (LBW), and low Apgar score. Of these, LBW (<2,500 g) in patients with EoE compared to controls correlated to an OR of 12.42 (95% CI = 1.26-122.42); however, this finding was based on very low numbers. The remaining fetal outcomes were not significantly different between females with EoE and controls. Secondary pregnancy and maternal outcomes including induction of labor, instrumental delivery, gestational diabetes, or pre-eclampsia were not significantly different between patients with EoE and controls. Discussion/Conclusion Overall in this nationwide cohort study, we did not find increased association of preterm birth in patients with EoE.
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Affiliation(s)
- Lovisa Röjler
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
| | - Amiko M. Uchida
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah School of Medicine, Salt Lake City, UT, USA
- Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John J. Garber
- Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Söderling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Bjorn Roelstraete
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F. Ludvigsson
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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16
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Xu H, Holowko N, Näslund I, Ottosson J, Arkema EV, Neovius M, Stephansson O, Johansson K. Pregnancy Weight Gain After Gastric Bypass or Sleeve Gastrectomy. JAMA Netw Open 2023; 6:e2346228. [PMID: 38051528 DOI: 10.1001/jamanetworkopen.2023.46228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
Importance Pregnancy weight gain may affect the association of bariatric surgery with postsurgery pregnancy outcomes. However, the association of pregnancy weight gain with bariatric surgery is unclear. Objective To compare pregnancy weight gain among women with a history of bariatric surgery vs those without and to investigate whether pregnancy weight gain differs by surgical procedure, surgery-to-conception interval, and/or surgery-to-conception weight loss. Design, Setting, and Participants This nationwide, population-based matched cohort study was conducted in Sweden from 2014 to 2021. Singleton pregnancies with a history of bariatric surgery were propensity score matched (1:1) to pregnancies without such a history according to early-pregnancy body mass index (BMI), prepregnancy diabetes, prepregnancy hypertension, maternal age, smoking status, education level, height, country of birth, and delivery year. In addition, post-gastric bypass pregnancies were matched to post-sleeve gastrectomy pregnancies using the same matching strategy. Data analysis was performed from November 2022 to May 2023. Exposure History of bariatric surgery. Main Outcomes and Measures Pregnancy weight gain was standardized by gestational age into early-pregnancy BMI-specific z scores. Results This study included 12 776 pregnancies, of which 6388 had a history of bariatric surgery and 6388 were matched controls. The mean (SD) age was 31.6 (4.9) years for the surgery group and 31.4 (5.2) for the matched controls, with an early-pregnancy mean (SD) BMI of 29.4 (5.2) in both groups. Across all early-pregnancy BMI strata, women with a history of bariatric surgery had lower pregnancy weight gain than matched controls. The differences in pregnancy weight gain z score values between the 2 groups were -0.33 (95% CI, -0.43 to -0.23) for normal weight, -0.33 (95% CI, -0.40 to -0.27) for overweight, -0.21 (95% CI, -0.29 to -0.13) for obese class I, -0.16 (95% CI, -0.29 to -0.03) for obese class II, and -0.08 (95% CI, -0.28 to 0.13) for obese class III. Pregnancy weight gain did not differ by surgical procedure. A shorter surgery-to-conception interval (particularly within 1 year) or lower surgery-to-conception weight loss was associated with lower pregnancy weight gain. Conclusions and Relevance In this nationwide matched cohort study, women with a history of bariatric surgery had lower pregnancy weight gain than matched controls with similar early-pregnancy characteristics. Pregnancy weight gain was lower in those with a shorter surgery-to-conception interval or lower surgery-to-conception weight loss, but did not differ by surgical procedure.
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Affiliation(s)
- Huiling Xu
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Natalie Holowko
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Ingmar Näslund
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Johan Ottosson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Elizabeth V Arkema
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Martin Neovius
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Kari Johansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
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17
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Mantel Ä, Sandström A, Faxén J, Andersson DC, Razaz N, Cnattingius S, Stephansson O. Pregnancy-Induced Hypertensive Disorder and Risks of Future Ischemic and Nonischemic Heart Failure. JACC Heart Fail 2023; 11:1216-1228. [PMID: 37178088 DOI: 10.1016/j.jchf.2023.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/31/2023] [Accepted: 03/24/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Although adverse pregnancy outcomes are associated with an increased risk of cardiovascular disease, studies on timing and subtypes of heart failure after a hypertensive pregnancy are lacking. OBJECTIVES The goal of this study was to assess the association between pregnancy-induced hypertensive disorder and risk of heart failure, according to ischemic and nonischemic subtypes, and the impact of disease characteristics and the timing of heart failure risks. METHODS This was a population-based matched cohort study, comprising all primiparous women without a history of cardiovascular disease included in the Swedish Medical Birth Register between 1988 and 2019. Women with pregnancy-induced hypertensive disorder were matched with women with normotensive pregnancies. Through linkage with health care registers, all women were followed up for incident heart failure, classified as ischemic or nonischemic. RESULTS In total, 79,334 women with pregnancy-induced hypertensive disorder were matched with 396,531 women with normotensive pregnancies. During a median follow-up of 13 years, rates of all heart failure subtypes were more common among women with pregnancy-induced hypertensive disorder. Compared with women with normotensive pregnancies, adjusted HRs (aHRs) with 95% CIs were as follows: heart failure overall, aHR: 1.70 (95% CI: 1.51-1.91); ischemic heart failure, aHR: 2.28 (95% CI: 1.74-2.98); and nonischemic heart failure, aHR: 1.60 (95% CI: 1.40-1.83). Disease characteristics indicating severe hypertensive disorder were associated with higher heart failure rates, and rates were highest within the first years after the hypertensive pregnancy but remained significantly increased thereafter. CONCLUSIONS Pregnancy-induced hypertensive disorder is associated with an increased short-term and long-term risk of incident ischemic and nonischemic heart failure. Disease characteristics indicating more severe forms of pregnancy-induced hypertensive disorder amplify the heart failure risks.
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Affiliation(s)
- Ängla Mantel
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institute, Stockholm, Sweden; Theme Women's Health, Department of Obstetrics, Karolinska University Hospital, Stockholm, Sweden.
| | - Anna Sandström
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institute, Stockholm, Sweden; Theme Women's Health, Department of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Faxén
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Daniel C Andersson
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Neda Razaz
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institute, Stockholm, Sweden
| | - Sven Cnattingius
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institute, Stockholm, Sweden
| | - Olof Stephansson
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institute, Stockholm, Sweden; Theme Women's Health, Department of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
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Lundborg L, Åberg K, Sandström A, Liu X, Tilden EL, Bolk J, Ladfors LV, Stephansson O, Ahlberg M. First stage of labour duration and associated risk of adverse neonatal outcomes. Sci Rep 2023; 13:12569. [PMID: 37532775 PMCID: PMC10397187 DOI: 10.1038/s41598-023-39480-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 07/26/2023] [Indexed: 08/04/2023] Open
Abstract
Prior evidence evaluating the benefits and harms of expectant labour duration during active first stage is inconclusive regarding potential consequences for the neonate. Population-based cohort study in Stockholm-Gotland region, Sweden, including 46,040 women (Robson 1), between October 1st, 2008 and June 15th, 2020. Modified Poisson regression was used for the association between active first stage of labour duration and adverse neonatal outcomes. 94.2% experienced a delivery with normal neonatal outcomes. Absolute risk for severe outcomes increased from 1.9 to 3.0%, moderate outcomes increased from 2.8 to 6.2% (> 10.1 h). Compared to the reference, (< 5.1 h; median), the adjusted relative risk (aRR) of severe neonatal outcome significantly increased beyond 10.1 h (> 90th percentile) (aRR 1.53, 95% CI 1.26, 1.87), for moderate neonatal outcome the aRR began to slowly increase beyond 5.1 h (≥ 50 percentile; aRR 1.40, 95% CI 1.24, 1.58). Mediation analysis indicate that most of the association was due to a longer active first stage of labour, 13% (severe neonatal outcomes) and 20% (moderate neonatal outcomes) of the risk was mediated (indirect effect) by longer second stage of labour duration. We report an association between increasing active first stage duration and increased risk of adverse neonatal outcomes. We did not observe a clear labour duration risk threshold.
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Affiliation(s)
- Louise Lundborg
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
| | - Katarina Åberg
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anna Sandström
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Xingrong Liu
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ellen L Tilden
- Department of Nurse-Midwifery, Oregon Health & Science University School of Nursing, Portland, OR, USA
- Department of Obstetrics and Gynecology, Oregon Health & Science University School of Medicine, Portland, OR, USA
| | - Jenny Bolk
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, South General Hospital, Stockholm, Sweden
| | - Linnea V Ladfors
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Mia Ahlberg
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
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19
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Zylberberg HM, Lebwohl B, Roelstraete B, Söderling J, Stephansson O, Green PHR, Ludvigsson JF. No Increased Risk of Cardiac Birth Defects in Infants of Mothers With Celiac Disease: A Population and Sibling Comparison. Am J Gastroenterol 2023; 118:1419-1427. [PMID: 37040545 DOI: 10.14309/ajg.0000000000002288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/27/2023] [Indexed: 04/13/2023]
Abstract
INTRODUCTION Several earlier studies have indicated an increased risk of cardiac birth defects among infants born to mothers with celiac disease (CeD). Through linking nationwide Swedish health care registries, we aimed to investigate maternal CeD and risk of any or cardiac birth defects in their offspring. METHODS We performed a retrospective cohort study of infants born between 2002 and 2016 to women with biopsy-proven CeD (villous atrophy, Marsh III) matched to infants born to nonceliac women from the general population. Conditional logistic regression with odds ratios (OR) and their 95% confidence intervals (CI) was used to determine the association between maternal CeD and birth defects. To minimize the impact of intrafamilial confounding, we also compared infants born to mothers with CeD with infants born to their nonaffected sisters. RESULTS A total of 6,990 infants were born to mothers with diagnosed CeD compared with 34,643 infants born to reference mothers. Any birth defect was seen in 234 (33 per 1,000 infants) and 1,244 (36/1,000) reference infants corresponding to an OR of 0.93 (95% CI 0.81-1.08). Cardiac birth defects were seen in 113 (16/1,000) vs 569 (16/1,000) infants (OR 0.98, 95% CI 0.80-1.20). Similar OR for any and cardiac birth defects were also seen in sibling comparisons. DISCUSSION We found no statistically significant risk of any or cardiac birth defects in infants born to mothers with diagnosed CeD compared with the general population and to their nonaffected sisters.
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Affiliation(s)
- Haley M Zylberberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Benjamin Lebwohl
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Celiac Disease Center, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York, USA
| | - Bjorn Roelstraete
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Söderling
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Peter H R Green
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Celiac Disease Center, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York, USA
| | - Jonas F Ludvigsson
- Celiac Disease Center, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York, USA
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
- Department of Pediatrics, Orebro University Hospital, Orebro, Sweden
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20
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Ekström MM, Tiblad E, Norman M, Stephansson O, Granfors M. Maternal, pregnancy and neonatal outcomes in triplet pregnancies in Sweden - a nationwide cohort study. Ups J Med Sci 2023; 128:9473. [PMID: 37538405 PMCID: PMC10395261 DOI: 10.48101/ujms.v128.9473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/25/2023] [Accepted: 05/30/2023] [Indexed: 08/05/2023] Open
Abstract
Background Triplet pregnancies carry a high risk of pregnancy-related complications. The primary aim of this study was to describe maternal, pregnancy, and neonatal outcomes in expectantly managed triplet pregnancies in Sweden. The secondary aim was to compare outcomes in expectantly managed triplet pregnancies with triplet pregnancies where fetal reduction had been performed with the only indication to reduce the number of fetuses. Methods Nationwide cohort study based on linkage of data from three national Swedish registers. Triplet pregnancies with delivery at gestational age ≥ 22+0 weeks between 2014 and 2019 were included. Results In the main cohort of expectantly managed triplet pregnancies (n = 106), 98% (312/318) of infants were liveborn with a mean gestational age at birth of 32+3 weeks and a mean birthweight of 1,726 g. Nine percent (n = 29) suffered from severe neonatal morbidity, and 4% (n = 12) died during the neonatal period. In the reduced cohort (n = 13 pregnancies), all infants were liveborn (n = 22). Mean gestational age at birth (36+0 weeks) and mean birthweight (2,444 g) were higher than in the expectantly managed cohort (P < 0.01 for both comparisons). There were no cases of severe neonatal morbidity (P = 0.24) or mortality (P = 1.00). Conclusion Overall neonatal survival from 22+0 weeks of gestation in expectantly managed triplet pregnancies in Sweden was high. Nine out of 10 infants did not suffer from severe neonatal morbidity. Fetal reduction was performed in only a very small number of cases and was associated with higher gestational age at birth and higher birth weight.
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Affiliation(s)
- Mia-Maria Ekström
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Eleonor Tiblad
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women’s Health, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Norman
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women’s Health, Karolinska University Hospital, Stockholm, Sweden
| | - Michaela Granfors
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics, Department of Women’s Health, Karolinska University Hospital, Stockholm, Sweden
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21
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Mantel Ä, Vassiliou D, Lissing M, Stephansson O, Wahlin S, Sardh E. Maternal and fetal outcomes in acute hepatic porphyria: A Swedish National Cohort Study. J Inherit Metab Dis 2023; 46:675-686. [PMID: 37078226 DOI: 10.1002/jimd.12616] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/22/2023] [Accepted: 04/19/2023] [Indexed: 04/21/2023]
Abstract
Current knowledge of pregnancy and perinatal outcomes in women with acute hepatic porphyria (AHP) is largely based on biochemical disease models, case reports, and case series. We performed a nationwide, registered-based cohort study to investigate the association between maternal AHP and the risk of adverse pregnancy and perinatal outcomes. All women in the Swedish Porphyria Register with confirmed AHP aged 18 years or older between 1987 and 2015 and matched general population comparators, with at least one registered delivery in the Swedish Medical Birth Register were included. Risk ratios (RRs) of pregnancy complications, delivery mode and perinatal outcomes were estimated and adjusted for maternal age at delivery, area of residency, birth year and parity. Women with acute intermittent porphyria (AIP), the most common form of AHP, were further categorized according to maximal lifetime urinary porphobilinogen (U-PBG) levels. The study included 214 women with AHP and 2174 matched comparators. Women with AHP presented with a higher risk for pregnancy-induced hypertensive disorder (aRR 1.73, 95% CI 1.12-2.68), gestational diabetes (aRR 3.41, 95% CI 1.69-6.89), and small-for-gestational-age birth (aRR 2.08, 95% CI 1.26-3.45). In general, RRs were higher among women with AIP who had high lifetime U-PBG levels. Our study shows an increased risk for pregnancy induced hypertensive disease, gestational diabetes, and small for gestational age births for AHP women, with higher relative risks for women with biochemically active AIP. No increased risk for perinatal death or malformations was observed.
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Affiliation(s)
- Ängla Mantel
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
- Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Daphne Vassiliou
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Centre for Inherited Metabolic Diseases, Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Lissing
- Hepatology Division, Karolinska University Hospital, Stockholm, Sweden
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
- Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Staffan Wahlin
- Hepatology Division, Karolinska University Hospital, Stockholm, Sweden
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Eliane Sardh
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Centre for Inherited Metabolic Diseases, Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Fernández de la Cruz L, Joseph KS, Wen Q, Stephansson O, Mataix-Cols D, Razaz N. Pregnancy, Delivery, and Neonatal Outcomes Associated With Maternal Obsessive-Compulsive Disorder: Two Cohort Studies in Sweden and British Columbia, Canada. JAMA Netw Open 2023; 6:e2318212. [PMID: 37314804 DOI: 10.1001/jamanetworkopen.2023.18212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
Importance Obsessive-compulsive disorder (OCD) is associated with adverse health-related outcomes. However, pregnancy and neonatal outcomes among women with OCD have been sparsely studied. Objective To evaluate associations of maternal OCD with pregnancy, delivery, and neonatal outcomes. Design, Setting, and Participants Two register-based cohort studies in Sweden and British Columbia (BC), Canada, included all singleton births at 22 weeks or more of gestation between January 1, 1999 (Sweden), or April 1, 2000 (BC), and December 31, 2019. Statistical analyses were conducted between August 1, 2022, and February 14, 2023. Exposure Maternal OCD diagnosis recorded before childbirth and use of serotonin reuptake inhibitors (SRIs) during pregnancy. Main Outcomes and Measures Pregnancy and delivery outcomes examined were gestational diabetes, preeclampsia, maternal infection, antepartum hemorrhage or placental abruption, premature rupture of membranes, induction of labor, mode of delivery, and postpartum hemorrhage. Neonatal outcomes included perinatal death, preterm birth, small for gestational age, low birth weight (<2500 g), low 5-minute Apgar score, neonatal hypoglycemia, neonatal jaundice, neonatal respiratory distress, neonatal infections, and congenital malformations. Multivariable Poisson log-linear regressions estimated crude and adjusted risk ratios (aRRs). In the Swedish cohort, sister and cousin analyses were performed to account for familial confounding. Results In the Swedish cohort, 8312 pregnancies in women with OCD (mean [SD] age at delivery, 30.2 [5.1] years) were compared with 2 137 348 pregnancies in unexposed women (mean [SD] age at delivery, 30.2 [5.1] years). In the BC cohort, 2341 pregnancies in women with OCD (mean [SD] age at delivery, 31.0 [5.4] years) were compared with 821 759 pregnancies in unexposed women (mean [SD] age at delivery, 31.3 [5.5] years). In Sweden, maternal OCD was associated with increased risks of gestational diabetes (aRR, 1.40; 95% CI, 1.19-1.65) and elective cesarean delivery (aRR, 1.39; 95% CI, 1.30-1.49), as well as preeclampsia (aRR, 1.14; 95% CI, 1.01-1.29), induction of labor (aRR, 1.12; 95% CI, 1.06-1.18), emergency cesarean delivery (aRR, 1.16; 95% CI, 1.08-1.25), and postpartum hemorrhage (aRR, 1.13; 95% CI, 1.04-1.22). In BC, only emergency cesarean delivery (aRR, 1.15; 95% CI, 1.01-1.31) and antepartum hemorrhage or placental abruption (aRR, 1.48; 95% CI, 1.03-2.14) were associated with significantly higher risk. In both cohorts, offspring of women with OCD were at elevated risk of low Apgar score at 5 minutes (Sweden: aRR, 1.62; 95% CI, 1.42-1.85; BC: aRR, 2.30; 95% CI, 1.74-3.04), as well as preterm birth (Sweden: aRR, 1.33; 95% CI, 1.21-1.45; BC: aRR, 1.58; 95% CI, 1.32-1.87), low birth weight (Sweden: aRR, 1.28; 95% CI, 1.14-1.44; BC: aRR, 1.40; 95% CI, 1.07-1.82), and neonatal respiratory distress (Sweden: aRR, 1.63; 95% CI, 1.49-1.79; BC: aRR, 1.47; 95% CI, 1.20-1.80). Women with OCD taking SRIs during pregnancy had an overall increased risk of these outcomes, compared with those not taking SRIs. However, women with OCD not taking SRIs still had increased risks compared with women without OCD. Sister and cousin analyses showed that at least some of the associations were not influenced by familial confounding. Conclusion and Relevance These cohort studies suggest that maternal OCD was associated with an increased risk of adverse pregnancy, delivery, and neonatal outcomes. Improved collaboration between psychiatry and obstetric services and improved maternal and neonatal care for women with OCD and their children is warranted.
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Affiliation(s)
- Lorena Fernández de la Cruz
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Qi Wen
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Olof Stephansson
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Neda Razaz
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Örtqvist AK, Magnus MC, Dahlqvist E, Söderling J, Johansson K, Sandström A, Håberg SE, Stephansson O. Association between SARS-CoV-2 infection and newly diagnosed hypertension during pregnancy: prospective, population based cohort study. BMJ Med 2023; 2:e000465. [PMID: 37275554 PMCID: PMC10230329 DOI: 10.1136/bmjmed-2022-000465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 04/26/2023] [Indexed: 06/07/2023]
Abstract
Objective To study the association between SARS-CoV-2 infection and newly diagnosed hypertension during pregnancy. Design Prospective, population based cohort study. Setting All singleton pregnancies after 22 completed gestational weeks registered in the Swedish Pregnancy Register and the Medical Birth Registry of Norway, from 1 March 2020 to 24 May 2022. Participants 312 456 individuals available for analysis (201 770 in Sweden and 110 686 in Norway), with pregnancies that reached 42 completed gestational weeks by the end of follow-up in the pregnancy registries, excluding individuals with SARS-CoV-2 infection before pregnancy and those with a diagnosis of pre-existing hypertension or onset of hypertension before 20 gestational weeks. Main outcome measures Newly diagnosed hypertension during pregnancy was defined as a composite outcome of a diagnosis of gestational hypertension, pre-eclampsia, HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome, or eclampsia, from gestational week 20 to one week after delivery. The association between SARS-CoV-2 infection and hypertension during pregnancy was investigated with a stratified Cox proportional hazard model, adjusting for maternal age, body mass index, parity, smoking, region of birth, education, income, coexisting medical conditions, previous hypertension during pregnancy, number of healthcare visits during the past year, and vaccination against SARS-CoV-2. Pre-eclampsia was also analysed as a separate outcome. Results Of 312 456 individuals available for analysis, 8% (n=24 566) had SARS-CoV-2 infection any time during pregnancy, 6% (n=18 051) had a diagnosis of hypertension during pregnancy, and 3% (9899) had pre-eclampsia. SARS-CoV-2 infection during pregnancy was not associated with an increased risk of hypertension during pregnancy (adjusted hazard ratio 0.99, 95% confidence interval 0.93 to 1.04) or pre-eclampsia (0.98, 0.87 to 1.10). The results were similar for SARS-CoV-2 infection in all gestational trimesters and in different time periods that corresponded to dominance of different variants of the SARS-CoV-2 virus. Conclusions This population based study did not find any evidence of an association between SARS-CoV-2 infection during pregnancy and an increased risk of hypertension during pregnancy or pre-eclampsia.
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Affiliation(s)
- Anne K. Örtqvist
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Visby Hospital, Visby, Sweden
| | - Maria C. Magnus
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Elisabeth Dahlqvist
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Söderling
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Kari Johansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women’s Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Sandström
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women’s Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Siri E. Håberg
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women’s Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
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Cao Y, Zhao S, Bexelius TS, Söderling J, Shi M, Roelstraete B, Warner BB, Stephansson O, Ludvigsson JF. Pregnancy and neonatal outcomes among women with early-onset colorectal cancer: a nationwide case-control study. EClinicalMedicine 2023; 59:101963. [PMID: 37125404 PMCID: PMC10139893 DOI: 10.1016/j.eclinm.2023.101963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Background Early-onset colorectal cancer has risen worldwide, leaving more women with colorectal cancer at reproductive ages. We aimed to investigate the risk of adverse pregnancy and neonatal outcomes among women with early-onset colorectal cancer. Methods We conducted a nationwide, matched case-control study of maternal/pregnancy outcomes including pre-eclampsia and Cesarean delivery (C-section) as well as neonatal outcomes including preterm birth among 207 births in women with early-onset colorectal cancer (ages 18-49) and 1019 births in women without colorectal cancer in Sweden (1992-2019). Early-onset colorectal cancer cases were identified through the Cancer Register, and outcome data were retrieved through linkage to Medical Birth Register and National Patient Register. Using conditional logistic regression, we estimated multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Findings Between Jan 1, 1992, and Dec 31, 2019, women with early-onset colorectal cancer who gave birth had increased odds of pre-eclampsia (7.2% vs 3.2%; OR = 2.52, 95%CI = 1.25-5.08), any C-section (24.6% vs 19.4%; OR = 1.43, 95%CI = 1.00-2.06), particularly emergency C-section (17.4% vs 10.5%; OR = 1.79, 95%CI = 1.17-2.75), after adjustment for maternal education level, country of birth, body mass index and smoking in early pregnancy, and comorbidities. Maternal history of early-onset colorectal cancer was also associated with offspring preterm birth (12.1% vs 5.2%; OR = 2.31, 95%CI = 1.34-3.99), delineated as spontaneous (OR = 1.06, 95%CI = 0.47-2.39) or medically-indicated preterm birth (OR = 4.48, 95%CI = 2.05-9.79). There was no increased risk of congenital malformation or small for gestational age birth. Interpretation In this population-based study, maternal history of early-onset colorectal cancer was associated with risk of both adverse pregnancy (pre-eclampsia, C-section) and neonatal outcomes (preterm birth). Funding US National Institutes of Health, Swedish Society of Medicine, Swedish Cancer Foundation.
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Affiliation(s)
- Yin Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Stephanie Zhao
- School of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Tomas S. Bexelius
- Department of Women's and Children's Health, Childhood Cancer Research Unit and Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatric Oncology, Astrid Lindgren Children Hospital, Stockholm, Sweden
| | - Jonas Söderling
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Mengyao Shi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Bjorn Roelstraete
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Barbara B. Warner
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, MO, USA
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Women's Health, Department of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas F. Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA
- Corresponding author. Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, PO Box 281, SE-17177, Stockholm, Sweden.
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25
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Zhang T, Mantel Ä, Runeson B, Sidorchuk A, Rück C, Stephansson O, Larsson H, Chang Z, Mataix-Cols D, Fernández de la Cruz L. Maternal suicide attempts and deaths in the first year after cesarean delivery. Psychol Med 2023; 53:3056-3064. [PMID: 34911599 PMCID: PMC10235649 DOI: 10.1017/s0033291721005109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/11/2021] [Accepted: 11/23/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cesarean delivery (CD) has been associated with postpartum psychiatric disorders, but less is known about the risk of suicidal behaviors. We estimated the incidence and risk of suicide attempts and deaths during the first postpartum year in mothers who delivered via CD v. vaginally. METHOD All deliveries in Sweden between 1973 and 2012 were identified. The mothers were followed since delivery for 12 months or until the date of one of the outcomes (i.e. suicide attempt or death by suicide), death by other causes or emigration. Associations were estimated using Cox proportional hazards regression models. RESULTS Of 4 016 789 identified deliveries, 514 113 (12.8%) were CDs and 3 502 676 (87.2%) were vaginal deliveries. During the 12-month follow-up, 504 (0.098%) suicide attempts were observed in the CD group and 2240 (0.064%) in the vaginal delivery group (risk difference: 0.034%), while 11 (0.0037%) deaths by suicide were registered in the CD group and 109 (0.0029%) in the vaginal delivery group (risk difference: 0.008%). Compared to vaginal delivery, CD was associated with an increased risk of suicide attempts [hazard ratio (HR) 1.46; 95% CI 1.32-1.60], but not of deaths by suicide (HR 1.44; 95% CI 0.88-2.36). CONCLUSIONS Maternal suicidal behaviors during the first postpartum year were uncommon in Sweden. Compared to vaginal delivery, CD was associated with a small increased risk of suicide attempts, but not death by suicide. Improved understanding of the association between CD and maternal suicidal behaviors may promote more appropriate measures to improve maternal mental well-being and further reduce suicidal risks.
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Affiliation(s)
- Tianyang Zhang
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Ängla Mantel
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Bo Runeson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Anna Sidorchuk
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Christian Rück
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Olof Stephansson
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Lorena Fernández de la Cruz
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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26
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Cao Y, Nguyen LH, Tica S, Otegbeye E, Zong X, Roelstraete B, Chan AT, Warner BB, Stephansson O, Ludvigsson JF. Evaluation of Birth by Cesarean Delivery and Development of Early-Onset Colorectal Cancer. JAMA Netw Open 2023; 6:e2310316. [PMID: 37103933 PMCID: PMC10140807 DOI: 10.1001/jamanetworkopen.2023.10316] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Importance The incidence of early-onset colorectal cancer (CRC), diagnosed younger than 50 years of age, has increased worldwide. Gut dysbiosis throughout the life course is hypothesized as a leading mechanism, yet epidemiologic data are limited. Objective To prospectively examine the association between birth by cesarean delivery and early-onset CRC among offspring. Design, Setting, and Participants In this population-based, nationwide case-control study in Sweden, adults diagnosed with CRC between 18 and 49 years of age from 1991 to 2017 were identified through the Epidemiology Strengthened by Histopathology Reports in Sweden (ESPRESSO) cohort. Up to 5 general population control individuals without CRC were matched with each case on age, sex, calendar year, and county of residence. Pathology-confirmed end points were linked with the Swedish Medical Birth Register and other national registers. Analyses were conducted from March 2022 through March 2023. Exposure Birth by cesarean delivery. Main Outcomes and Measures The primary outcome was development of early-onset CRC in the overall population and by sex. Results We identified 564 case patients with incident early-onset CRC (mean [SD] age, 32.9 [6.2] years; 284 [50.4%] male) and 2180 matched controls (mean [SD] age, 32.7 [6.3] years; 1104 [50.6%] male). Compared with vaginal delivery, birth by cesarean delivery was not associated with early-onset CRC in the overall population (adjusted odds ratio [aOR], 1.28; 95% CI, 0.91-1.79) after multivariable adjustment for matching and maternal and pregnancy-related factors. A positive association was found for females (aOR, 1.62; 95% CI, 1.01-2.60), but there was no association for males (aOR, 1.05; 95% CI, 0.64-1.72). Conclusions and Relevance In this nationwide, population-based case-control study, birth by cesarean delivery was not associated with early-onset CRC compared with birth by vaginal delivery in the overall population in Sweden. However, females born by cesarean delivery had greater odds of early-onset CRC compared with individuals born through vaginal delivery. This finding suggests that early-life gut dysbiosis may contribute to early-onset CRC in females.
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Affiliation(s)
- Yin Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Long H Nguyen
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Stefani Tica
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Ebunoluwa Otegbeye
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Xiaoyu Zong
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Bjorn Roelstraete
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Barbara B Warner
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Women's Health, Department of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
- Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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27
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Calvert C, Brockway MM, Zoega H, Miller JE, Been JV, Amegah AK, Racine-Poon A, Oskoui SE, Abok II, Aghaeepour N, Akwaowo CD, Alshaikh BN, Ayede AI, Bacchini F, Barekatain B, Barnes R, Bebak K, Berard A, Bhutta ZA, Brook JR, Bryan LR, Cajachagua-Torres KN, Campbell-Yeo M, Chu DT, Connor KL, Cornette L, Cortés S, Daly M, Debauche C, Dedeke IOF, Einarsdóttir K, Engjom H, Estrada-Gutierrez G, Fantasia I, Fiorentino NM, Franklin M, Fraser A, Gachuno OW, Gallo LA, Gissler M, Håberg SE, Habibelahi A, Häggström J, Hookham L, Hui L, Huicho L, Hunter KJ, Huq S, Kc A, Kadambari S, Kelishadi R, Khalili N, Kippen J, Le Doare K, Llorca J, Magee LA, Magnus MC, Man KKC, Mburugu PM, Mediratta RP, Morris AD, Muhajarine N, Mulholland RH, Bonnard LN, Nakibuuka V, Nassar N, Nyadanu SD, Oakley L, Oladokun A, Olayemi OO, Olutekunbi OA, Oluwafemi RO, Ogunkunle TO, Orton C, Örtqvist AK, Ouma J, Oyapero O, Palmer KR, Pedersen LH, Pereira G, Pereyra I, Philip RK, Pruski D, Przybylski M, Quezada-Pinedo HG, Regan AK, Rhoda NR, Rihs TA, Riley T, Rocha TAH, Rolnik DL, Saner C, Schneuer FJ, Souter VL, Stephansson O, Sun S, Swift EM, Szabó M, Temmerman M, Tooke L, Urquia ML, von Dadelszen P, Wellenius GA, Whitehead C, Wong ICK, Wood R, Wróblewska-Seniuk K, Yeboah-Antwi K, Yilgwan CS, Zawiejska A, Sheikh A, Rodriguez N, Burgner D, Stock SJ, Azad MB. Changes in preterm birth and stillbirth during COVID-19 lockdowns in 26 countries. Nat Hum Behav 2023; 7:529-544. [PMID: 36849590 PMCID: PMC10129868 DOI: 10.1038/s41562-023-01522-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 01/06/2023] [Indexed: 03/01/2023]
Abstract
Preterm birth (PTB) is the leading cause of infant mortality worldwide. Changes in PTB rates, ranging from -90% to +30%, were reported in many countries following early COVID-19 pandemic response measures ('lockdowns'). It is unclear whether this variation reflects real differences in lockdown impacts, or perhaps differences in stillbirth rates and/or study designs. Here we present interrupted time series and meta-analyses using harmonized data from 52 million births in 26 countries, 18 of which had representative population-based data, with overall PTB rates ranging from 6% to 12% and stillbirth ranging from 2.5 to 10.5 per 1,000 births. We show small reductions in PTB in the first (odds ratio 0.96, 95% confidence interval 0.95-0.98, P value <0.0001), second (0.96, 0.92-0.99, 0.03) and third (0.97, 0.94-1.00, 0.09) months of lockdown, but not in the fourth month of lockdown (0.99, 0.96-1.01, 0.34), although there were some between-country differences after the first month. For high-income countries in this study, we did not observe an association between lockdown and stillbirths in the second (1.00, 0.88-1.14, 0.98), third (0.99, 0.88-1.12, 0.89) and fourth (1.01, 0.87-1.18, 0.86) months of lockdown, although we have imprecise estimates due to stillbirths being a relatively rare event. We did, however, find evidence of increased risk of stillbirth in the first month of lockdown in high-income countries (1.14, 1.02-1.29, 0.02) and, in Brazil, we found evidence for an association between lockdown and stillbirth in the second (1.09, 1.03-1.15, 0.002), third (1.10, 1.03-1.17, 0.003) and fourth (1.12, 1.05-1.19, <0.001) months of lockdown. With an estimated 14.8 million PTB annually worldwide, the modest reductions observed during early pandemic lockdowns translate into large numbers of PTB averted globally and warrant further research into causal pathways.
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Affiliation(s)
- Clara Calvert
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Meredith Merilee Brockway
- Children's Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Helga Zoega
- School of Population Health, Faculty of Medicine & Health, University of New South Wales Sydney, Sydney, New South Wales, Australia
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Jessica E Miller
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Jasper V Been
- Division of Neonatology, Department of Paediatrics; Department of Obstetrics and Gynaecology; Department of Public Health; Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Adeladza Kofi Amegah
- Public Health Research Group, Department of Biomedical Sciences, University of Cape Coast, Cape Coast, Ghana
| | | | | | - Ishaya I Abok
- Department of Pediatrics, University of Jos/Jos University Teaching Hospital, Jos, Nigeria
| | - Nima Aghaeepour
- Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Christie D Akwaowo
- Institute of Health Research and Development, University of Uyo Teaching Hospital, Uyo, Nigeria
- College of Health Sciences, University of Uyo, Uyo, Nigeria
| | - Belal N Alshaikh
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Adejumoke I Ayede
- Department of Pediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | | | - Behzad Barekatain
- Department of Pediatrics, Division of Neonatology, Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Karolina Bebak
- Obstetrics and Gynaecology Ward, District Public Hospital in Poznań, Poznań, Poland
| | - Anick Berard
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
- CHU Ste-Justine, Montreal, Quebec, Canada
- Faculty of Medicine, Université Claude Bernard Lyon 1, Lyon, France
| | - Zulfiqar A Bhutta
- Center of Excellence in Women Child Health, The Aga Khan University, Karachi, Pakistan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeffrey R Brook
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Lenroy R Bryan
- Department of Obstetrics & Gynaecology and Child Health, University of The West MonaIndies, Mona, Jamaica
| | - Kim N Cajachagua-Torres
- The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- The Department of Paediatrics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Centro de Investigación en Salud Materna e Infantil and Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Marsha Campbell-Yeo
- School of Nursing, Dalhousie University and IWK Health, Halifax, Nova Scotia, Canada
| | - Dinh-Toi Chu
- Center for Biomedicine and Community Health, International School, Vietnam National University, Hanoi, Vietnam
| | - Kristin L Connor
- Department of Health Sciences, Carleton University, Ottawa, Ontario, Canada
| | - Luc Cornette
- AZ St-Jan Bruges-Ostend AV Hospital, Bruges, Belgium
| | - Sandra Cortés
- Department of Public Health, School of Medicine, Advanced Center for Chronic Diseases Diagonal (ACCDIS), Santiago, Chile
| | - Mandy Daly
- Irish Neonatal Health Alliance, Wicklow, Ireland
| | - Christian Debauche
- Department of Neonatology, Cliniques Universitaires Saint-Luc, IREC, UCLouvain, Brussels, Belgium
- CEpiP (Centre d'Epidémiologie Périnatale), Brussels, Belgium
| | | | - Kristjana Einarsdóttir
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Hilde Engjom
- Department of Health Registry Research and Development, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Ilaria Fantasia
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo Children's Hospital, Trieste, Italy
| | - Nicole M Fiorentino
- Children's Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Meredith Franklin
- Department of Statistical Sciences and School of the Environment, University of Toronto, Toronto, Ontario, Canada
| | - Abigail Fraser
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Onesmus W Gachuno
- Obstetrics and Gynecology, Medicine, University of Nairobi, Nairobi, Kenya
| | - Linda A Gallo
- School of Biomedical Sciences, The University of Queensland, St. Lucia, Queensland, Australia
| | - Mika Gissler
- Department of Knowledge Brokers, THL Finnish Institute for Health and Welfare, Helsinki, Finland
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Siri E Håberg
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Abbas Habibelahi
- Neonatology, Neonatal Health Office, Ministry of Health and Medical Education, Tehran, Iran
| | | | - Lauren Hookham
- St. George's University, Makerere University - Johns Hopkins University Research Collaboration, London, UK
| | - Lisa Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Luis Huicho
- Centro de Investigación en Salud Materna e Infantil, Centro de Investigación para el Desarrollo Integral y Sostenible and School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Sayeeda Huq
- Nutrition and Clinical Services Division, ICDDR,B (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | | | - Seilesh Kadambari
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Roya Kelishadi
- Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Narjes Khalili
- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Joanna Kippen
- Obstetrics and Gynaecology Ward, District Public Hospital in Poznań, Poznań, Poland
| | - Kirsty Le Doare
- International Centre for Neonatal and Paediatric Infection, St. George's, University of London, London, UK
- Medical Research Council/Uganda Virus Research Institute and London School of Medical Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Javier Llorca
- Universidad de Cantabria, Santander, Spain
- CIBERESP (Consortium for Biomedical Research in Epidemiology & Public Health, en Epidemiología y Salud Pública), Madrid, Spain
| | - Laura A Magee
- Institute of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
| | - Maria C Magnus
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Kenneth K C Man
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong, Hong Kong
| | - Patrick M Mburugu
- Department of Child Health and Paediatrics, School of Medicine, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Rishi P Mediratta
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Nazeem Muhajarine
- Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Livia Nagy Bonnard
- Melletted a helyem Egyesület, Right(s) Beside You Association, Budapest, Hungary
| | - Victoria Nakibuuka
- Department of Paediatrics, St. Francis Nsambya Hospital, Kampala, Uganda
| | - Natasha Nassar
- Child Population and Translational Health Research, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Sylvester D Nyadanu
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
- Education, Culture, and Health Opportunities (ECHO) Research Group International, Aflao, Ghana
| | - Laura Oakley
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Adesina Oladokun
- Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | - Oladapo O Olayemi
- Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | | | - Rosena O Oluwafemi
- Department of Paediatrics and Child Health, Mother and Child Hospital, Akure, Nigeria
| | - Taofik O Ogunkunle
- Department of Paediatrics, Dalhatu Araf Specialist Hospital, Lafia, Nigeria
| | | | - Anne K Örtqvist
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Visby County Hospital, Visby, Sweden
| | - Joseph Ouma
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Oyejoke Oyapero
- Paediatrics Department, Ikorodu General Hospital, Ikorodu, Nigeria
| | - Kirsten R Palmer
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Lars H Pedersen
- Department of Obstetrics and Gynecology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Gavin Pereira
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
- Curtin School of Population Health and enAble Institute, Curtin University, Perth, Western Australia, Australia
| | - Isabel Pereyra
- School of Nutrition, Catholic University del Maule, Region del Maule, Chile
| | - Roy K Philip
- Division of Neonatology, Department of Paediatrics, University Maternity Hospital Limerick and University of Limerick School of Medicine, Limerick, Ireland
| | - Dominik Pruski
- Obstetrics and Gynaecology Ward, District Public Hospital in Poznań, Poznań, Poland
| | - Marcin Przybylski
- Obstetrics and Gynaecology Ward, District Public Hospital in Poznań, Poznań, Poland
| | - Hugo G Quezada-Pinedo
- The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- The Department of Paediatrics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Centro de Investigación en Salud Materna e Infantil and Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Annette K Regan
- School of Nursing and Health Professions, University of San Francisco, San Francisco, CA, USA
| | - Natasha R Rhoda
- Paediatric Department, School of Adolescent and Child Health, University of Cape Town, Cape Town, South Africa
- Mowbray Maternity Hospital, Western Cape Department of Health, Cape Town, South Africa
| | - Tonia A Rihs
- Federal Statistical Office (FSO), Neuchâtel, Switzerland
| | - Taylor Riley
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Thiago Augusto Hernandes Rocha
- Evidence and Intelligence for Action in Health Department, Pan-American Health Organization - World Health Organization, Washington, DC, USA
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Christoph Saner
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Francisco J Schneuer
- The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Shengzhi Sun
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA
| | - Emma M Swift
- Faculty of Nursing, Department of Midwifery, University of Iceland, Reykjavík, Iceland
| | - Miklós Szabó
- Division of Neonatology, 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Lloyd Tooke
- Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| | - Marcelo L Urquia
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Peter von Dadelszen
- Institute of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
| | - Gregory A Wellenius
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA
| | - Clare Whitehead
- The Royal Women's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Ian C K Wong
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong, Hong Kong
| | - Rachael Wood
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Public Health Scotland, Edinburgh, UK
| | | | - Kojo Yeboah-Antwi
- Public Health Unit, Father Thomas Alan Rooney Memorial Hospital, Asankrangwa, Western Region, Ghana
| | | | - Agnieszka Zawiejska
- Department of Medical Simulation, Chair of Medical Education, Poznań University of Medical Sciences, Poznań, Poland
| | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Natalie Rodriguez
- Children's Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Burgner
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.
| | - Sarah J Stock
- Usher Institute, University of Edinburgh, Edinburgh, UK.
| | - Meghan B Azad
- Children's Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada.
- Departments of Pediatrics and Child Health, Community Health Sciences, and Immunology, University of Manitoba, Winnipeg, Manitoba, Canada, Winnipeg, Manitoba, Canada.
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Örtqvist AK, Magnus MC, Aabakke AJM, Urhoj SK, Vinkel Hansen A, Nybo Andersen AM, Krebs L, Pettersson K, Håberg SE, Stephansson O. Severe COVID-19 during pregnancy in Sweden, Norway, and Denmark. Acta Obstet Gynecol Scand 2023; 102:681-689. [PMID: 36928990 DOI: 10.1111/aogs.14552] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Pregnancy is a risk factor for severe coronavirus disease 2019 (COVID-19) and adverse pregnancy outcomes. We aimed to explore maternal characteristics, pregnancy outcomes, vaccination status, and virus variants among pregnant women admitted to intensive care units (ICU) with severe COVID-19. MATERIAL AND METHODS We identified pregnant women admitted to ICU in Sweden (n = 96), Norway (n = 31), and Denmark (n = 16) because of severe COVID-19, from national registers and clinical databases between March 2020 and February 2022 (Denmark), August 2022 (Sweden), or December 2022 (Norway). Their background characteristics, pregnancy outcome, and vaccination status were compared with all birthing women and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test-positive pregnant women during the same time period. We calculated the number admitted to ICU per 10 000 birthing and per 1000 SARS-CoV-2 test-positive women during the Index, Alpha, Delta, and Omicron periods. RESULTS Women admitted to ICU had a higher mean body mass index, were more often of non-Scandinavian origin, had on average lower education and income levels, had a higher proportion of chronic and pregnancy-related conditions, delivered preterm, had neonates with low Apgar scores, and had more infants admitted to neonatal care, compared with all birthing and test-positive pregnant women. Of those admitted to ICU, only 7% had been vaccinated before admission. Overall, the highest proportion of women admitted to ICU per birthing was during the Delta period (4.1 per 10 000 birthing women). In Norway, the highest proportion admitted to ICU per test-positive pregnant women was during the Delta period (17.8 per 1000 test-positive), whereas the highest proportion of admitted per test-positive in Sweden and Denmark was seen during the Index period (15.4 and 8.9 per 1000 test-positive, respectively). CONCLUSIONS Admission to ICU because of COVID-19 in pregnancy was a rare event in the Scandinavian countries, but women who were unvaccinated, of non-Scandinavian origin, and with lower socio-economic status were at higher risk of admission to ICU. In addition, women admitted to ICU for COVID-19 had higher risk of adverse pregnancy outcomes.
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Affiliation(s)
- Anne K Örtqvist
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynecology, Visby County Hospital, Visby, Sweden
| | - Maria C Magnus
- Center for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Anna J M Aabakke
- Department of Obstetrics and Gynecology, Copenhagen University Hospital-Holbaek, Holbaek, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Obstetrics and Gynecology, Copenhagen University Hospital-Northzealand-Hillerød, Hillerød, Denmark
| | - Stine Kjaer Urhoj
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anne Vinkel Hansen
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Statistics Denmark, Copenhagen, Denmark
| | | | - Lone Krebs
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Obstetrics and Gynecology, Copenhagen University Hospital-Hvidovre, Hvidovre, Denmark
| | - Karin Pettersson
- Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Division of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Siri E Håberg
- Center for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Division of Women's Health, Karolinska University Hospital, Stockholm, Sweden
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29
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Holowko N, Haas J, Ahlberg M, Stephansson O, Örtqvist A. More than time: travel time to the delivery ward and maternal outcomes - onset of labour, postpartum haemorrhage and obstetric anal sphincter injury. Public Health 2023; 217:105-114. [PMID: 36871510 DOI: 10.1016/j.puhe.2023.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Closing delivery units increases travel time for some women. Whether increased travel time is associated with maternal outcomes is important for understanding the consequences of such closures. Previous studies are limited in measuring travel time and restricted to the outcome of caesarean section. METHODS Our population-based cohort includes data from the Swedish Pregnancy Register for women giving birth between 2014 and 2017 (N = 364,630). We estimated travel time from home to the delivery ward using coordinate pairs of actual addresses. The association between travel time and onset of labour was modelled using multinomial logistic regression, and logistic regression was used for the outcomes postpartum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS). FINDINGS Over three-quarters of women had ≤30 min travel time (median 13.9 min). Women who travelled ≥60 min arrived to care sooner and laboured there longer. Women with further to travel had increased adjusted odds ratio (aOR) of having an elective caesarean section (31-59 min aOR 1.11; 95% confidence interval [CI] 1.07-1.16; ≥60 min aOR 1.25; 95% CI 1.16-1.36) than spontaneous onset of labour. Women (at full term with spontaneous onset) living ≥60 min away had reduced odds of having a PPH (aOR 0.84; 95% CI 0.76-0.94) or OASIS (aOR 0.79; 95% CI 0.66-0.94). INTERPRETATION Longer travel time increased the odds of elective caesarean section. Women with furthest to travel arrived sooner and spent more time in care; although they had a lower risk of PPH or OASIS, they also tended to be younger, have a higher body mass index and were Nordic born.
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Affiliation(s)
- N Holowko
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - J Haas
- Department of Environmental and Life Sciences, Faculty of Healthy, Science and Technology, Geomatics, Karlstad University, Karlstad, Sweden
| | - M Ahlberg
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Women's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - O Stephansson
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Women's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - A Örtqvist
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynaecology, Visby County Hospital, Visby, Sweden
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30
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Morin M, Frisell T, Stephansson O, Hellgren K. Temporal trends in adverse pregnancy outcomes in axial spondyloarthritis in Sweden: a cohort study. Lancet Rheumatol 2023; 5:e121-e129. [PMID: 38251608 DOI: 10.1016/s2665-9913(23)00001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Evidence on the risks associated with pregnancy and childbirth in women with axial spondyloarthritis is scarce and conflicting, with more research needed to guide policy and clinical practice. We aimed to assess the risks of adverse pregnancy outcomes in a large cohort of women with axial spondyloarthritis, and to investigate how outcomes varied over time and in relation to anti-rheumatic treatment. METHODS In this register-based cohort study, we included births in Sweden between April 1, 2007, and Dec 31, 2020, to women with axial spondyloarthritis and general population comparators, matched 1:10 on year of delivery, maternal age, and parity. Our main data source was the Medical Birth Register (MBR), which includes over 98% of births in Sweden and prospectively collects data on antenatal care, delivery, and foetal outcomes. The information in MBR was linked to other registers, including the National Patient Register, the Prescribed Drug Register, and registers with demographic data. Our main outcomes were the relative risks of adverse pregnancy outcomes, analysed using modified Poisson regression. We also studied how the frequency of certain adverse outcomes, as well as disease-modifying antirheumatic drug (DMARD) and non-steroidal anti-inflammatory drug treatments, changed over the study period by linear regression and loess plots. FINDINGS Between April 1, 2007, and Dec 31, 2020, 1580 births in women with axial spondyloarthritis recorded in MBR fulfilled the inclusion criteria and were matched with 15 792 comparator births. Among the 1580 births in women with axial spondyloarthritis, we found increased risks of preterm birth (risk ratio 1·43, 95% CI 1·13-1·80), pre-eclampsia (1·44, 1·08-1·92), elective caesarean delivery (1·59, 1·37-1·84), and serious infant infection (1·29, 1·05-1·59) compared with births in general population comparators. The risks of preterm birth, infant infection, and caesarean delivery decreased by around 0·5 percentage points annually during the study period, while the use of tumour necrosis factor inhibitors during pregnancy increased. INTERPRETATION In view of remaining concerns regarding safety of the use of biological DMARDs during pregnancy, we saw a reassuring trend in which pregnancy outcomes improved over time in the axial spondyloarthritis group, concurrent with increased use of biological DMARDs. If the current rate of improvement is maintained, women with axial spondyloarthritis treated in accordance with clinical guidelines might eventually not be at an increased risk of adverse pregnancy outcomes. FUNDING Swedish Research Council and The Swedish Rheumatism Association.
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Affiliation(s)
- Matilda Morin
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Karin Hellgren
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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31
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Smith ER, Oakley E, Grandner GW, Rukundo G, Farooq F, Ferguson K, Baumann S, Adams Waldorf KM, Afshar Y, Ahlberg M, Ahmadzia H, Akelo V, Aldrovandi G, Bevilacqua E, Bracero N, Brandt JS, Broutet N, Carrillo J, Conry J, Cosmi E, Crispi F, Crovetto F, Del Mar Gil M, Delgado-López C, Divakar H, Driscoll AJ, Favre G, Fernandez Buhigas I, Flaherman V, Gale C, Godwin CL, Gottlieb S, Gratacós E, He S, Hernandez O, Jones S, Joshi S, Kalafat E, Khagayi S, Knight M, Kotloff KL, Lanzone A, Laurita Longo V, Le Doare K, Lees C, Litman E, Lokken EM, Madhi SA, Magee LA, Martinez-Portilla RJ, Metz TD, Miller ES, Money D, Moungmaithong S, Mullins E, Nachega JB, Nunes MC, Onyango D, Panchaud A, Poon LC, Raiten D, Regan L, Sahota D, Sakowicz A, Sanin-Blair J, Stephansson O, Temmerman M, Thorson A, Thwin SS, Tippett Barr BA, Tolosa JE, Tug N, Valencia-Prado M, Visentin S, von Dadelszen P, Whitehead C, Wood M, Yang H, Zavala R, Tielsch JM. Clinical risk factors of adverse outcomes among women with COVID-19 in the pregnancy and postpartum period: a sequential, prospective meta-analysis. Am J Obstet Gynecol 2023; 228:161-177. [PMID: 36027953 PMCID: PMC9398561 DOI: 10.1016/j.ajog.2022.08.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/04/2022] [Accepted: 08/07/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE This sequential, prospective meta-analysis sought to identify risk factors among pregnant and postpartum women with COVID-19 for adverse outcomes related to disease severity, maternal morbidities, neonatal mortality and morbidity, and adverse birth outcomes. DATA SOURCES We prospectively invited study investigators to join the sequential, prospective meta-analysis via professional research networks beginning in March 2020. STUDY ELIGIBILITY CRITERIA Eligible studies included those recruiting at least 25 consecutive cases of COVID-19 in pregnancy within a defined catchment area. METHODS We included individual patient data from 21 participating studies. Data quality was assessed, and harmonized variables for risk factors and outcomes were constructed. Duplicate cases were removed. Pooled estimates for the absolute and relative risk of adverse outcomes comparing those with and without each risk factor were generated using a 2-stage meta-analysis. RESULTS We collected data from 33 countries and territories, including 21,977 cases of SARS-CoV-2 infection in pregnancy or postpartum. We found that women with comorbidities (preexisting diabetes mellitus, hypertension, cardiovascular disease) vs those without were at higher risk for COVID-19 severity and adverse pregnancy outcomes (fetal death, preterm birth, low birthweight). Participants with COVID-19 and HIV were 1.74 times (95% confidence interval, 1.12-2.71) more likely to be admitted to the intensive care unit. Pregnant women who were underweight before pregnancy were at higher risk of intensive care unit admission (relative risk, 5.53; 95% confidence interval, 2.27-13.44), ventilation (relative risk, 9.36; 95% confidence interval, 3.87-22.63), and pregnancy-related death (relative risk, 14.10; 95% confidence interval, 2.83-70.36). Prepregnancy obesity was also a risk factor for severe COVID-19 outcomes including intensive care unit admission (relative risk, 1.81; 95% confidence interval, 1.26-2.60), ventilation (relative risk, 2.05; 95% confidence interval, 1.20-3.51), any critical care (relative risk, 1.89; 95% confidence interval, 1.28-2.77), and pneumonia (relative risk, 1.66; 95% confidence interval, 1.18-2.33). Anemic pregnant women with COVID-19 also had increased risk of intensive care unit admission (relative risk, 1.63; 95% confidence interval, 1.25-2.11) and death (relative risk, 2.36; 95% confidence interval, 1.15-4.81). CONCLUSION We found that pregnant women with comorbidities including diabetes mellitus, hypertension, and cardiovascular disease were at increased risk for severe COVID-19-related outcomes, maternal morbidities, and adverse birth outcomes. We also identified several less commonly known risk factors, including HIV infection, prepregnancy underweight, and anemia. Although pregnant women are already considered a high-risk population, special priority for prevention and treatment should be given to pregnant women with these additional risk factors.
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Affiliation(s)
- Emily R Smith
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC.
| | - Erin Oakley
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Gargi Wable Grandner
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Gordon Rukundo
- PeriCOVID (PREPARE)-Uganda Team, Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Fouzia Farooq
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Kacey Ferguson
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Sasha Baumann
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Kristina Maria Adams Waldorf
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA; Department of Global Health, University of Washington, Seattle, WA
| | - Yalda Afshar
- Division of Maternal-Fetal Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Mia Ahlberg
- Division of Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Homa Ahmadzia
- Division of Maternal-Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Victor Akelo
- Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Grace Aldrovandi
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA
| | - Elisa Bevilacqua
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Nabal Bracero
- Department of Obstetrics and Gynecology, University of Puerto Rico School of Medicine, San Juan, PR; Puerto Rico Obstetrics and Gynecology (PROGyn)
| | - Justin S Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Natalie Broutet
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Jorge Carrillo
- Departamento de Obstetricia y Ginecologia, Clinica Alemana de Santiago, Facultad de Medicina Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Jeanne Conry
- International Federation of Gynecology and Obstetrics, London, United Kingdom
| | - Erich Cosmi
- Department of Women's and Children's Health, Obstetrics and Gynecology Clinic, University of Padua, Padua, Italy
| | - Fatima Crispi
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Sant Joan de Déu Barcelona and Hospital Clínic de Barcelona, Universitat de Barcelona, and Center for Biomedical Research on Rare Diseases, Barcelona, Spain
| | - Francesca Crovetto
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Sant Joan de Déu Barcelona and Hospital Clínic de Barcelona, Universitat de Barcelona, and Center for Biomedical Research on Rare Diseases, Barcelona, Spain
| | - Maria Del Mar Gil
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Madrid, Spain; School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Camille Delgado-López
- Surveillance for Emerging Threats to Mothers and Babies, Puerto Rico Department of Health, San Juan, PR
| | - Hema Divakar
- Asian Research & Training Institute for Skill Transfer, Bengaluru, India
| | - Amanda J Driscoll
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD
| | - Guillaume Favre
- Materno-fetal and Obstetrics Research Unit, Département Femme-Mère-Enfant, Lausanne University Hospital, Lausanne, Switzerland
| | - Irene Fernandez Buhigas
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Madrid, Spain; School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Valerie Flaherman
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Christopher Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Christine L Godwin
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Sami Gottlieb
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Eduard Gratacós
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Sant Joan de Déu Barcelona and Hospital Clínic de Barcelona, Universitat de Barcelona, and Center for Biomedical Research on Rare Diseases, Barcelona, Spain
| | - Siran He
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Olivia Hernandez
- Gynecology and Obstetrics, Félix Bulnes Hospital and RedSalud Clinic, Santiago, Chile
| | - Stephanie Jones
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit and Department of Science and Technology/National Research Foundation, South African Research Chair Initiative in Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sheetal Joshi
- Asian Research & Training Institute for Skill Transfer, Bengaluru, India
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, School of Medicine, Koç University, Istanbul, Turkey
| | - Sammy Khagayi
- Kenya Medical Research Institute-Centre for Global Health Research, Kisumu, Kenya
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Karen L Kotloff
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD
| | - Antonio Lanzone
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy; Catholic University of Sacred Heart, Rome, Italy
| | - Valentina Laurita Longo
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy; Catholic University of Sacred Heart, Rome, Italy
| | - Kirsty Le Doare
- PeriCOVID (PREPARE)-Uganda Team, Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda; Medical Research Council /Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda; Paediatric Infectious Disease Research Group, St George's University of London, London, United Kingdom
| | - Christoph Lees
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Ethan Litman
- Division of Maternal-Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Erica M Lokken
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA; Department of Global Health, University of Washington, Seattle, WA
| | - Shabir A Madhi
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit and Department of Science and Technology/National Research Foundation, South African Research Chair Initiative in Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom; Institute of Women and Children's Health, King's College Hospital, London, United Kingdom
| | | | - Torri D Metz
- Division of Maternal-Fetal Medicine, The University of Utah Health, Salt Lake City, UT
| | - Emily S Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Deborah Money
- Department of Obstetrics and Gynecology, The University of British Columbia, Vancouver, Canada
| | - Sakita Moungmaithong
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong
| | - Edward Mullins
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom; George Institute for Global Health, London, United Kingdom
| | - Jean B Nachega
- Department of Epidemiology and Center for Global Health, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA; Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Marta C Nunes
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit and Department of Science and Technology/National Research Foundation, South African Research Chair Initiative in Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Alice Panchaud
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland; Service of Pharmacy, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong
| | - Daniel Raiten
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Lesley Regan
- International Federation of Gynecology and Obstetrics, Imperial College London, London, United Kingdom
| | - Daljit Sahota
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong
| | - Allie Sakowicz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jose Sanin-Blair
- Maternal-Fetal Unit, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Olof Stephansson
- Division of Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Anna Thorson
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Soe Soe Thwin
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Beth A Tippett Barr
- Centers for Disease Control and Prevention, Kisumu, Kenya; Nyanja Health Research Institute, Salima, Malawi
| | - Jorge E Tolosa
- Maternal-Fetal Unit, Universidad Pontificia Bolivariana, Medellín, Colombia; Department of Obstetrics and Gynecology, Maternal Fetal Medicine, Oregon Health & Science University, Portland, OR; Department of Obstetrics and Gynecology, Maternal Fetal Medicine, St. Luke's University Health Network, Bethlehem, PA
| | - Niyazi Tug
- Department of Obstetrics and Gynecology, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, Istanbul, Turkey
| | - Miguel Valencia-Prado
- Division of Children with Special Medical Needs, Puerto Rico Department of Health, San Juan, PR
| | - Silvia Visentin
- Department of Women's and Children's Health, Obstetrics and Gynecology Clinic, University of Padua, Padua, Italy
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom; Global Health Institute, King's College London, London, United Kingdom
| | - Clare Whitehead
- Department of Maternal Fetal Medicine, University of Melbourne, Royal Women's Hospital, Melbourne, Australia
| | - Mollie Wood
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Rebecca Zavala
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - James M Tielsch
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
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Brismar Wendel S, Liu C, Stephansson O. The association between episiotomy or OASIS at vacuum extraction in nulliparous women and subsequent prelabor cesarean delivery: A nationwide observational study. Acta Obstet Gynecol Scand 2023; 102:378-388. [PMID: 36691864 PMCID: PMC9951312 DOI: 10.1111/aogs.14513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 12/28/2022] [Accepted: 01/02/2023] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Severe perineal injuries at childbirth affect women's postnatal health, including future childbirths. First births with vacuum extraction carry an increased risk of obstetric anal sphincter injuries (OASIS). Lateral or mediolateral episiotomy at vacuum extraction may decrease the risk of OASIS. Our aim was to assess whether lateral or mediolateral episiotomy, or OASIS, at vacuum extraction in nulliparous women is associated with prelabor cesarean delivery in the subsequent childbirth. MATERIAL AND METHODS This is a nationwide observational study using data from the Swedish Medical Birth Register, including women having a first birth with vacuum extraction and a second birth in 2000-2014. Both births were live, single, cephalic, ≥34 gestational weeks without malformations. The association between episiotomy or OASIS in the first birth and prelabor cesarean delivery in the second birth was examined using univariate and multivariate logistic regression with inverse probability of treatment weighting, and interaction analysis. Main outcome measure was prelabor cesarean delivery in the second birth. RESULTS In total, 44 656 women with vacuum extraction at their first birth were included. The rate of prelabor cesarean delivery in the second birth was 5.9% (824 of 13 950) in women with episiotomy, compared with 6.0% (1830 of 30 706) in women without episiotomy. Thus, women with episiotomy did not have an increased risk of prelabor cesarean delivery (adjusted odds ratio [aOR] 1.00, 95% confidence interval [95% CI] 0.83-1.20) compared with women without episiotomy. For comparison, the rate of prelabor cesarean delivery in the second birth was 20.6% (1275 of 6176) in women with OASIS, compared with 3.6% (1379 of 38 480) in women without OASIS (aOR 6.57, 95% CI 5.97-7.23). There was no interaction between episiotomy and OASIS. CONCLUSIONS Lateral or mediolateral episiotomy at vacuum extraction in nulliparous women did not increase the risk of prelabor cesarean delivery in the subsequent childbirth. OASIS increased the odds of prelabor cesarean delivery more than sixfold.
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Affiliation(s)
- Sophia Brismar Wendel
- Department of Clinical SciencesKarolinska Institutet, Danderyd HospitalStockholmSweden,Department of Women's HealthDanderyd HospitalStockholmSweden,Clinical Epidemiology Division, Department of MedicineKarolinska InstitutetStockholmSweden
| | - Can Liu
- Clinical Epidemiology Division, Department of MedicineKarolinska InstitutetStockholmSweden,Department of Public Health SciencesStockholm UniversityStockholmSweden,Centre for Health Equity Studies (CHESS)Stockholm University/Karolinska InstitutetStockholmSweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of MedicineKarolinska InstitutetStockholmSweden,Department of Women's Health, Division of ObstetricsKarolinska University HospitalStockholmSweden
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Ladfors LV, Liu X, Sandström A, Lundborg L, Snowden JM, Ahlberg M, Stephansson O. First stage labor duration and the risk of postpartum hemorrhage - a population-based cohort study. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Smith ER, Oakley E, Grandner GW, Ferguson K, Farooq F, Afshar Y, Ahlberg M, Ahmadzia H, Akelo V, Aldrovandi G, Tippett Barr BA, Bevilacqua E, Brandt JS, Broutet N, Fernández Buhigas I, Carrillo J, Clifton R, Conry J, Cosmi E, Crispi F, Crovetto F, Delgado-López C, Divakar H, Driscoll AJ, Favre G, Flaherman VJ, Gale C, Gil MM, Gottlieb SL, Gratacós E, Hernandez O, Jones S, Kalafat E, Khagayi S, Knight M, Kotloff K, Lanzone A, Le Doare K, Lees C, Litman E, Lokken EM, Laurita Longo V, Madhi SA, Magee LA, Martinez-Portilla RJ, McClure EM, Metz TD, Miller ES, Money D, Moungmaithong S, Mullins E, Nachega JB, Nunes MC, Onyango D, Panchaud A, Poon LC, Raiten D, Regan L, Rukundo G, Sahota D, Sakowicz A, Sanin-Blair J, Söderling J, Stephansson O, Temmerman M, Thorson A, Tolosa JE, Townson J, Valencia-Prado M, Visentin S, von Dadelszen P, Adams Waldorf K, Whitehead C, Yassa M, Tielsch JM. Adverse maternal, fetal, and newborn outcomes among pregnant women with SARS-CoV-2 infection: an individual participant data meta-analysis. BMJ Glob Health 2023; 8:e009495. [PMID: 36646475 PMCID: PMC9895919 DOI: 10.1136/bmjgh-2022-009495] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/24/2022] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Despite a growing body of research on the risks of SARS-CoV-2 infection during pregnancy, there is continued controversy given heterogeneity in the quality and design of published studies. METHODS We screened ongoing studies in our sequential, prospective meta-analysis. We pooled individual participant data to estimate the absolute and relative risk (RR) of adverse outcomes among pregnant women with SARS-CoV-2 infection, compared with confirmed negative pregnancies. We evaluated the risk of bias using a modified Newcastle-Ottawa Scale. RESULTS We screened 137 studies and included 12 studies in 12 countries involving 13 136 pregnant women.Pregnant women with SARS-CoV-2 infection-as compared with uninfected pregnant women-were at significantly increased risk of maternal mortality (10 studies; n=1490; RR 7.68, 95% CI 1.70 to 34.61); admission to intensive care unit (8 studies; n=6660; RR 3.81, 95% CI 2.03 to 7.17); receiving mechanical ventilation (7 studies; n=4887; RR 15.23, 95% CI 4.32 to 53.71); receiving any critical care (7 studies; n=4735; RR 5.48, 95% CI 2.57 to 11.72); and being diagnosed with pneumonia (6 studies; n=4573; RR 23.46, 95% CI 3.03 to 181.39) and thromboembolic disease (8 studies; n=5146; RR 5.50, 95% CI 1.12 to 27.12).Neonates born to women with SARS-CoV-2 infection were more likely to be admitted to a neonatal care unit after birth (7 studies; n=7637; RR 1.86, 95% CI 1.12 to 3.08); be born preterm (7 studies; n=6233; RR 1.71, 95% CI 1.28 to 2.29) or moderately preterm (7 studies; n=6071; RR 2.92, 95% CI 1.88 to 4.54); and to be born low birth weight (12 studies; n=11 930; RR 1.19, 95% CI 1.02 to 1.40). Infection was not linked to stillbirth. Studies were generally at low or moderate risk of bias. CONCLUSIONS This analysis indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. As more data become available, we will update these findings per the published protocol.
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Affiliation(s)
- Emily R Smith
- Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Erin Oakley
- Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Gargi Wable Grandner
- Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Kacey Ferguson
- Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Fouzia Farooq
- Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Mia Ahlberg
- Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institute, Stockholm, Sweden
| | - Homa Ahmadzia
- Division of Maternal-Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Victor Akelo
- Office of the Director, US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Grace Aldrovandi
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Beth A Tippett Barr
- Office of the Director, US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Elisa Bevilacqua
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Roma, Italy
| | - Justin S Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Nathalie Broutet
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | | | - Jorge Carrillo
- Departamento de Obstetricia y Ginecologia, Universidad del Desarrollo Facultad de Medicina Clinica Alemana, Santiago, Chile
| | - Rebecca Clifton
- The Biostatistics Center, The George Washington University Milken Institute School of Public Health, Rockville, Maryland, USA
| | - Jeanne Conry
- International Federation of Gynecology and Obstetrics, London, UK
| | - Erich Cosmi
- Department of Women's and Children's Health, University of Padua, Padova, Italy
| | - Fatima Crispi
- Department of Maternal-Fetal Medicine, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Francesca Crovetto
- Department of Maternal-Fetal Medicine, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Camille Delgado-López
- Surveillance for Emerging Threats to Mothers and Babies, Puerto Rico Department of Health, San Juan, Puerto Rico
| | - Hema Divakar
- Asian Research and Training Institute for Skill Transfer (ARTIST), Bengaluru, India
| | - Amanda J Driscoll
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Guillaume Favre
- Materno-Fetal and Obstetrics Research Unit, Department ‘Femme-Mère-Enfant’, Lausanne University Hospital, Lausanne, Switzerland
| | - Valerie J Flaherman
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Imperial College London Faculty of Medicine, London, UK
| | - Maria M Gil
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Madrid, Spain
| | - Sami L Gottlieb
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Eduard Gratacós
- Department of Maternal-Fetal Medicine, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Olivia Hernandez
- Gynecology and Obstetrics, Felix Bulnes Hospital and RedSalud Clinic, Santiago, Chile
| | - Stephanie Jones
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, Koç University School of Medicine, Istanbul, Turkey
| | - Sammy Khagayi
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Marian Knight
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Karen Kotloff
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Antonio Lanzone
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Roma, Italy
| | - Kirsty Le Doare
- Uganda Virus Institute and the London School of Hygiene & Tropical Medicine, Entebbe, Uganda,Pediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - Christoph Lees
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Ethan Litman
- Division of Maternal-Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Erica M Lokken
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Valentina Laurita Longo
- Institute of Obstetrics and Gynecology Clinic, Catholic University of Sacred Heart, Rome, Italy
| | - Shabir A Madhi
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Laura A Magee
- Department of Women and Children’s Health, School of Life Course and Population Sciences, King's College London, London, UK
| | | | | | - Tori D Metz
- Departments of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake, Utah, USA
| | - Emily S Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Deborah Money
- Department of Obstetrics and Gynecology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sakita Moungmaithong
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Edward Mullins
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Jean B Nachega
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Marta C Nunes
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | | | - Alice Panchaud
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Daniel Raiten
- Pediatric Growth and Nutrition Branch, National Institute of Health, Bethesda, Maryland, USA
| | - Lesley Regan
- International Federation of Gynecology and Obstetrics, London, UK
| | - Gordon Rukundo
- Uganda Virus Institute and the London School of Hygiene & Tropical Medicine, Entebbe, Uganda
| | - Daljit Sahota
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Allie Sakowicz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jose Sanin-Blair
- Universidad Pontificia Bolivariana, Medellin, Antioquia, Colombia
| | - Jonas Söderling
- Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institute, Stockholm, Sweden
| | - Olof Stephansson
- Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institute, Stockholm, Sweden
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Anna Thorson
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Jorge E Tolosa
- Department of Obstetrics and Gynecology, St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Julia Townson
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Miguel Valencia-Prado
- Children with Special Medical Needs Division, Puerto Rico Department of Health, San Juan, Puerto Rico
| | - Silvia Visentin
- Department of Women's and Children's Health, University of Padua, Padova, Italy
| | - Peter von Dadelszen
- Department of Women and Children's Health, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Kristina Adams Waldorf
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Clare Whitehead
- Department of Maternal-Fetal Medicine, The Royal Women's Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Murat Yassa
- Department of Obstetrics and Gynecology, Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research Hospital, Istanbul, Turkey
| | - Jim M Tielsch
- Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
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Cnattingius S, Källén K, Sandström A, Rydberg H, Månsson H, Stephansson O, Frisell T, Ludvigsson JF. The Swedish medical birth register during five decades: documentation of the content and quality of the register. Eur J Epidemiol 2023; 38:109-120. [PMID: 36595114 PMCID: PMC9867659 DOI: 10.1007/s10654-022-00947-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/15/2022] [Indexed: 01/04/2023]
Abstract
Pregnancy-related factors are important for short- and long-term health in mothers and offspring. The nationwide population-based Swedish Medical Birth Register (MBR) was established in 1973. The present study describes the content and quality of the MBR, using original MBR data, Swedish-language and international publications based on the MBR.The MBR includes around 98% of all births in Sweden. From 1982 onwards, the MBR is based on prospectively recorded information in standardized antenatal, obstetric, and neonatal records. When the mother and infant are discharged from hospital, this information is forwarded to the MBR, which is updated annually. Maternal data include information from first antenatal visit on self-reported obstetric history, infertility, diseases, medication use, cohabitation status, smoking and snuff use, self-reported height and measured weight, allowing calculation of body mass index. Birth and neonatal data include date and time of birth, mode of delivery, singleton or multiple birth, gestational age, stillbirth, birth weight, birth length, head circumference, infant sex, Apgar scores, and maternal and infant diagnoses/procedures, including neonatal care. The overall quality of the MBR is very high, owing to the semi-automated data extraction from the standardized regional electronic health records, Sweden's universal access to antenatal care, and the possibility to compare mothers and offspring to the Total Population Register in order to identify missing records. Through the unique personal identity numbers of mothers and live-born offspring, the MBR can be linked to other health registers. The Swedish MBR contains high-quality pregnancy-related information on more than 5 million births during five decades.
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Affiliation(s)
- Sven Cnattingius
- grid.465198.7Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Karin Källén
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Centre of Reproduction Epidemiology, Tornblad Institute, Lund University, Lund, Sweden
| | - Anna Sandström
- grid.465198.7Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Solna, Sweden ,grid.24381.3c0000 0000 9241 5705Department of Women’s Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Henny Rydberg
- grid.416537.20000 0004 0511 9852Statistics Unit 1, Department of Registers and Statistics, National Board of Health and Welfare, Stockholm, Sweden
| | - Helena Månsson
- grid.416537.20000 0004 0511 9852Statistics Unit 1, Department of Registers and Statistics, National Board of Health and Welfare, Stockholm, Sweden
| | - Olof Stephansson
- grid.465198.7Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Solna, Sweden ,grid.24381.3c0000 0000 9241 5705Department of Women’s Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Frisell
- grid.465198.7Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Jonas F. Ludvigsson
- grid.4714.60000 0004 1937 0626Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17177 Stockholm, Sweden ,grid.412367.50000 0001 0123 6208Department of Pediatrics, Örebro University Hospital, Örebro, Sweden ,grid.21729.3f0000000419368729Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY USA
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Cao Y, Zhao S, Bexelius TS, Söderling J, Shi M, Roelstraete B, Warner BB, Stephansson O, Ludvigsson JF. Abstract P074: Pregnancy and neonatal outcomes among early-onset colorectal cancer survivors: a nationwide case-control study. Cancer Prev Res (Phila) 2023. [DOI: 10.1158/1940-6215.precprev22-p074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Abstract
Purpose: Early-onset colorectal cancer (CRC diagnosed before age 50) has risen worldwide, with an increasing number of survivors of reproductive age. We aimed to investigate the risk of adverse pregnancy and neonatal outcomes among early-onset CRC survivors. Methods: We conducted a nationwide case-control study of 207 births in women with early-onset CRC and 1019 births in women without CRC from the general Swedish population (1992-2019), matched on age, calendar year of birth, parity, and county of residence. To control for genetic susceptibility and shared childhood exposures, we additionally identified 146 births in female siblings of the CRC survivors. Early-onset CRC cases were identified through the Swedish Cancer Register (1969-2019), and siblings were identified through the Swedish Multi-generation Register. Maternal characteristics and neonatal outcomes were retrieved from the Swedish Medical Birth Register and National Patient Register. Using conditional logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results: Compared to women without prior CRC, early-onset CRC survivors who gave birth had increased risk of pre-eclampsia (aOR 2.52, 95% CI 1.25 to 5.08), induced labor (aOR 1.64, 95% CI 1.09 to 2.46) and emergency Cesarean section (aOR 1.79, 95% CI 1.17 to 2.75), after adjustment for maternal education level, country of birth, body mass index and smoking in early pregnancy, and comorbidities. Sibling analyses showed similar trends, especially for higher risk of induced labor (aOR 2.58, 95% CI 1.03 to 6.49). Maternal history of early-onset CRC was also associated with offspring preterm birth (aOR 2.31, 95% CI 1.34 to 3.99) and low birth weight (aOR 2.95, 95% CI 1.40 to 6.21), and risks were particularly pronounced for medically indicated preterm birth (aOR 4.48, 95% CI 2.05 to 9.79). No significant associations were found for small for gestational age birth, low Apgar score, and congenital malformations. Conclusion: In this population-based study, history of early-onset CRC was associated with increased risk of adverse pregnancy outcomes, including pre-eclampsia, induction of labor, and emergency Cesarean section. Offspring to mothers with early-onset CRC also had increased risk of medically indicated preterm birth and neonatal low birth weight.
Citation Format: Yin Cao, Stephanie Zhao, Tomas S. Bexelius, Jonas Söderling, Mengyao Shi, Bjorn Roelstraete, Barbara B. Warner, Olof Stephansson, Jonas F. Ludvigsson. Pregnancy and neonatal outcomes among early-onset colorectal cancer survivors: a nationwide case-control study. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P074.
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Affiliation(s)
- Yin Cao
- 1Washington University School of Medicine, St. Louis, MO,
| | - Stephanie Zhao
- 1Washington University School of Medicine, St. Louis, MO,
| | | | | | - Mengyao Shi
- 1Washington University School of Medicine, St. Louis, MO,
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Sharma R, Simon TG, Stephansson O, Verna EC, Emond J, Söderling J, Roelstraete B, Hagström H, Ludvigsson JF. Pregnancy Outcomes in Women With Autoimmune Hepatitis - A Nationwide Population-based Cohort Study With Histopathology. Clin Gastroenterol Hepatol 2023; 21:103-114.e10. [PMID: 34954339 DOI: 10.1016/j.cgh.2021.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/29/2021] [Accepted: 12/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Autoimmune hepatitis (AIH) is a chronic inflammatory liver condition that predominantly affects women. However, pregnancy risks remain unclear. METHODS A nationwide population-based cohort study (ESPRESSO) in Sweden from 1992 to 2016 including 309 singleton births in women with AIH and 1532 matched births in women from the general population was performed. AIH was diagnosed as a combination of administrative coding from medical diagnosis of AIH and liver biopsy data from Sweden's 28 pathology departments. Using conditional logistic regression, odds ratios (ORs) for adverse pregnancy outcomes were determined. RESULTS Among 306 live births to women with AIH, 51 (16.7%) were preterm, compared with 70 of 1524 (4.6%) reference births. This corresponded to an OR of 5.10 for preterm birth (95% confidence interval [CI], 3.29-7.92), with similar odds using sibling comparators. Women with AIH with and without cirrhosis had similar odds for preterm birth. The AIH association was particularly strong with medically indicated preterm birth (OR, 13.01; 95% CI, 5.50-30.79). AIH was associated with low birth weight (OR, 5.31; 95% CI, 2.82-9.99) and low 5-minute Apgar score (OR, 3.46; 95% CI, 1.14-10.49) offspring, but we found no association with congenital malformations (OR, 1.14; 95% CI, 0.68-1.91), small for gestational age (OR, 1.04; 95% CI, 0.38-2.85), stillbirth (OR, 0.59; 95% CI, 0.02-18.88), or neonatal death (OR, 7.42; 95% CI, 0.65-84.25). Maternal AIH was linked to an increased odds of cesarean section (OR, 1.44; 95% CI, 1.04-2.00) and preeclampsia (OR, 3.65; 95% CI, 2.01-6.64), but not to gestational diabetes. CONCLUSIONS Maternal AIH was associated with a 5-fold higher odds of preterm birth, and cirrhosis at diagnosis did not add to the impact of AIH on preterm birth. Future studies are needed to understand how to reduce this risk.
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Affiliation(s)
- Rajani Sharma
- Center for Liver Disease and Transplantation, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York; Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Tracey G Simon
- Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Olof Stephansson
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden; Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York; Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jean Emond
- Center for Liver Disease and Transplantation, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York
| | - Jonas Söderling
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Bjorn Roelstraete
- Unit of Hepatology, Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Hannes Hagström
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Unit of Hepatology, Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, UK.
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Johansson K, Granfors M, Petersson G, Bolk J, Altman M, Cnattingius S, Liu X, Sandström A, Stephansson O. The Stockholm-Gotland perinatal cohort-A population-based cohort including longitudinal data throughout pregnancy and the postpartum period. Paediatr Perinat Epidemiol 2022; 37:276-286. [PMID: 36560891 DOI: 10.1111/ppe.12945] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/23/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Register-based reproductive and perinatal databases rarely contain detailed information from medical records or repeated measurements throughout pregnancy and delivery. This lack of enriched pregnancy and birth data led to the initiation of the Swedish Stockholm-Gotland Perinatal Cohort (SGPC). OBJECTIVES To describe the strengths of the SGPC, as well as the unique research questions that can be addressed using this cohort. POPULATION The SGPC is a prospectively collected, population-based cohort that includes all births (from 22 completed gestational weeks onwards) between 1 January 2008 and 15 June 2020 in the Stockholm and Gotland regions of Sweden (N 335,153 singleton and N 11,025 multiple pregnancies). DESIGN Descriptive study. METHODS The SGPC is based on the electronic medical records of women and their infants. The medical record system is used for all antenatal clinic visits and admissions, delivery and neonatal admissions, as well as postpartum clinical visits. SGPC has been further enriched with data linkages to 10 Swedish National Health Care and Quality Registers. PRELIMINARY RESULTS In contrast to other reproductive and perinatal databases available in Sweden, including the Medical Birth Register and the Pregnancy Register, SGPC contains highly detailed medical record data, including time-varying serial measurements for physiological parameters throughout pregnancy, delivery, and postpartum, for both mother and infant. These strengths have enabled studies that were previously inconceivable; the effects of serial measurements of pregnancy weight gain, changes in haemoglobin counts and blood pressure during pregnancy, fetal weight estimations by ultrasound, duration of stages and phases of labour, cervical dilatation and oxytocin use during delivery, and constructing reference curves for umbilical cord pH. CONCLUSIONS The SGPC-with its rich content, repeated measurements and linkages to numerous health care and quality registers-is a unique cohort that enables high-quality perinatal studies that would otherwise not be possible.
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Affiliation(s)
- Kari Johansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Michaela Granfors
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Gunnar Petersson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jenny Bolk
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Sachs´ Children and Youth Hospital, Stockholm, Sweden.,Department of Clinical Science and Education Södersjukhuset Karolinska Institutet, Stockholm, Sweden
| | - Maria Altman
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Pediatric Rheumatology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Sven Cnattingius
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Xingrong Liu
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Sandström
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
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Magnus MC, Oakley LL, Hansen AV, Örtqvist AK, Petersen TG, Mortensen LH, Bliddal M, Andersen AMN, Stephansson O, Håberg SE. Fetal death after the introduction of COVID-19 mitigation measures in Sweden, Denmark and Norway: a registry-based study. Sci Rep 2022; 12:20625. [PMID: 36450919 PMCID: PMC9709372 DOI: 10.1038/s41598-022-25036-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Abstract
It remains unclear whether the rate of fetal death has changed during the COVID-19 pandemic. We assessed the impact of COVID-19 mitigation measures on fetal death in Sweden (449,347 births), Denmark (290,857 pregnancies) and Norway (261,057 pregnancies) using robust population-based registry data. We used Cox regression to assess the impact of the implementation of pandemic mitigation measures on March 12th, 2020, on miscarriage (fetal loss before gestational week 22) and stillbirth (fetal loss after gestational week 22). A total of 11% of 551,914 pregnancies in Denmark and Norway ended in miscarriage, while the proportion of stillbirths among 937,174 births across the three countries was 0.3%. There was no difference in the risk of fetal death during the year following pandemic mitigation measures. For miscarriage, the combined hazard ratio (HR) for Norway and Denmark was 1.01 (95% CI 0.98, 1.03), and for stillbirth, the combined HR for all three countries was 0.99 (95% CI 0.89, 1.09). We observed a slightly decreased risk of miscarriage during the first 4 months, with an HR of 0.94 (95% CI 0.90, 0.99) after lockdown. In conclusion, the risk of fetal death did not change after the implementation of COVID-19 pandemic mitigation measures in the three Scandinavian countries.
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Affiliation(s)
- Maria C. Magnus
- grid.418193.60000 0001 1541 4204Centre for Fertility and Health, Norwegian Institute of Public Health, P.O. Box 222 Skøyen, 0213 Oslo, Norway
| | - Laura L. Oakley
- grid.418193.60000 0001 1541 4204Centre for Fertility and Health, Norwegian Institute of Public Health, P.O. Box 222 Skøyen, 0213 Oslo, Norway ,grid.8991.90000 0004 0425 469XDepartment of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Anne V. Hansen
- grid.5254.60000 0001 0674 042XDepartment of Public Health, University of Copenhagen, Copenhagen, Denmark ,grid.437930.a0000 0001 2248 6353Statistics Denmark, Copenhagen, Denmark
| | - Anne K. Örtqvist
- grid.4714.60000 0004 1937 0626Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden ,Department of Obstetrics and Gynaecology, Visby County Hospital, Visby, Sweden
| | - Tanja G. Petersen
- grid.7143.10000 0004 0512 5013Open, Odense University Hospital, Odense, Denmark
| | - Laust H. Mortensen
- grid.5254.60000 0001 0674 042XDepartment of Public Health, University of Copenhagen, Copenhagen, Denmark ,grid.437930.a0000 0001 2248 6353Statistics Denmark, Copenhagen, Denmark
| | - Mette Bliddal
- grid.10825.3e0000 0001 0728 0170OPEN, University of Southern Denmark, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Clinical Pharmacology, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anne-Marie Nybo Andersen
- grid.5254.60000 0001 0674 042XDepartment of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Olof Stephansson
- grid.4714.60000 0004 1937 0626Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Department of Women’s Health, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Siri E. Håberg
- grid.418193.60000 0001 1541 4204Centre for Fertility and Health, Norwegian Institute of Public Health, P.O. Box 222 Skøyen, 0213 Oslo, Norway
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Mårild K, Söderling J, Stephansson O, Axelrad J, Halfvarson J, Bröms G, Marsal J, Olén O, Ludvigsson JF. Histological remission in inflammatory bowel disease and risk of adverse pregnancy outcomes: A nationwide study. EClinicalMedicine 2022; 53:101722. [PMID: 36467453 PMCID: PMC9716329 DOI: 10.1016/j.eclinm.2022.101722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) has been linked to adverse pregnancy outcomes, but it is unclear how risks vary by histological activity. METHODS We performed a nationwide study of Swedish women diagnosed with IBD 1990-2016 and a pre-pregnancy (<12 months) colorectal biopsy with vs. without histological inflammation (1223 and 630 births, respectively). We also examined pregnancy outcomes in 2007-2016 of women with vs. without clinically active IBD (i.e., IBD-related hospitalization, surgery, or medication escalation) <12 months before pregnancy (2110 and 4993 births, respectively). Accounting for smoking, socio-demographics, and comorbidities, generalized linear models estimated adjusted risk ratios (aRRs) for preterm birth (<37 gestational weeks) and small-for-gestational age (SGA, <10th percentile weight for age). FINDINGS Of infants to women with vs. without histological inflammation, 9.6% (n = 117) and 6.5% (n = 41) were preterm, respectively (aRR = 1.46; 95%CI = 1.03-2.06). Histological inflammation was associated with preterm birth in ulcerative colitis (UC) (aRR = 1.64; 95%CI = 1.07-2.52), especially extensive colitis (aRR = 2.37; 95%CI = 1.12-5.02), but not in Crohn's disease (aRR = 0.99; 95%CI = 0.55-1.78). Of infants to women with vs. without histological inflammation, 116 (9.6%) and 56 (8.9%), respectively, were SGA (aRR = 1.09; 95%CI = 0.81-1.47). Clinically active disease before pregnancy was linked to preterm birth (aRR = 1.42; 95%CI = 1.20-1.69), but not to SGA birth (aRR = 1.13; 95%CI = 0.96-1.32). Finally, of infants to women without clinical activity, histological inflammation was not significantly associated with preterm birth (aRR = 1.20; 95%CI = 0.68-2.13). INTERPRETATION Histological and clinical activity in IBD, especially in UC, were risk factors for preterm birth. Further research is needed to determine the importance of pre-pregnancy histological activity in women without clinically-defined disease activity. FUNDING The Swedish Society of Medicine.
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Affiliation(s)
- Karl Mårild
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Paediatrics, Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Jonas Söderling
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jordan Axelrad
- Inflammatory Bowel Disease Centre at NYU Langone Health, Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | - Gabriella Bröms
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Danderyd hospital, Stockholm, Sweden
| | - Jan Marsal
- Department of Gastroenterology, Skåne University Hospital, Lund, Sweden
- Immunology Section, Lund University, Lund, Sweden
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
- Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Remaeus K, Johansson K, Granath F, Stephansson O, Hellgren K. Reply. Arthritis Rheumatol 2022; 74:1720-1721. [PMID: 35666026 DOI: 10.1002/art.42254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/10/2022] [Indexed: 11/08/2022]
Affiliation(s)
| | | | | | - Olof Stephansson
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Karin Hellgren
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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de Bont J, Stafoggia M, Nakstad B, Hajat S, Kovats S, Part C, Chersich M, Luchters S, Filippi V, Stephansson O, Ljungman P, Roos N. Associations between ambient temperature and risk of preterm birth in Sweden: A comparison of analytical approaches. Environ Res 2022; 213:113586. [PMID: 35671796 DOI: 10.1016/j.envres.2022.113586] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/24/2022] [Accepted: 05/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Evidence indicates that high temperatures are a risk factor for preterm birth. Increasing heat exposures due to climate change are therefore a concern for pregnant women. However, the large heterogeneity of study designs and statistical methods across previous studies complicate interpretation and comparisons. We investigated associations of short-term exposure to high ambient temperature with preterm birth in Sweden, applying three complementary analytical approaches. METHODS We included 560,615 singleton live births between 2014 and 2019, identified in the Swedish Pregnancy Register. We estimated weekly mean temperatures at 1-km2 spatial resolution using a spatiotemporal machine learning methodology, and assigned them at the residential addresses of the study participants. The main outcomes of the study were gestational age in weeks and subcategories of preterm birth (<37 weeks): extremely preterm birth (<28 weeks), very preterm birth (from week 28 to <32), and moderately preterm birth (from week 32 to<37). Case-crossover, quantile regression and time-to-event analyses were applied to estimate the effects of short-term exposure to increased ambient temperature during the week before birth on preterm births. Furthermore, distributed lag nonlinear models (DLNM) were applied to identify susceptibility windows of exposures throughout pregnancy in relation to preterm birth. RESULTS A total of 1924 births were extremely preterm (0.4%), 2636 very preterm (0.5%), and 23,664 moderately preterm (4.2%). Consistent across all three analytical approaches (case-crossover, quantile regression and time-to-event analyses), higher ambient temperature (95th vs 50th percentile) demonstrated increased risk of extremely preterm birth, but associations did not reach statistical significance. In DLNM models, we observed no evidence to suggest an increased effect of high temperature on preterm birth risk. Even so, a suggested trend was observed in both the quantile regression and time-to-event analyses of a higher risk of extremely preterm birth with higher temperature during the last week before birth. CONCLUSIONS In Sweden, with high quality data on exposure and outcome, a temperate climate and good quality ante-natal health care, we did not find an association between high ambient temperatures and preterm births. Results were consistent across three complementary analytical approaches.
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Affiliation(s)
- Jeroen de Bont
- Institute of Environmental Medicine, Karolinska Institutet, Sweden.
| | - Massimo Stafoggia
- Institute of Environmental Medicine, Karolinska Institutet, Sweden; Department of Epidemiology, Lazio Region Health Service, ASL Roma 1, Italy
| | - Britt Nakstad
- Division Paediatric Adolescent Medicine, Inst Clinical Medicine, University of Oslo, Oslo, Norway; Department Paediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Shakoor Hajat
- Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, UK
| | - Sari Kovats
- Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, UK
| | - Chérie Part
- Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, UK
| | - Matthew Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Science, University of the Witwatersrand, South Africa
| | - Stanley Luchters
- Centre for Sexual Health and HIV/AIDS Research, CeSHHAR, Harare, Zimbabwe; Department of Public Health and Primary Care, Ghent University, Belgium; Liverpool School of Tropical Medicine, UK
| | - Veronique Filippi
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, UK
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Sweden
| | - Petter Ljungman
- Institute of Environmental Medicine, Karolinska Institutet, Sweden; Department of Cardiology, Danderyd University Hospital, Sweden
| | - Nathalie Roos
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Sweden
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Xu H, Hutcheon JA, Liu X, Stephansson O, Cnattingius S, Arkema EV, Johansson K. Risk of gestational diabetes mellitus in relation to early pregnancy and gestational weight gain before diagnosis: A population-based cohort study. Acta Obstet Gynecol Scand 2022; 101:1253-1261. [PMID: 36069213 PMCID: PMC9812107 DOI: 10.1111/aogs.14450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Gestational diabetes mellitus (GDM) is a common pregnancy complication associated with adverse consequences for the mother and offspring in both short and long term. The aim of this study was to investigate associations between risk of GDM and gestational weight gain in early pregnancy and before diagnosis. MATERIAL AND METHODS Our population-based cohort study included 131 164 singleton pregnancies in the Stockholm-Gotland region in Sweden from 2008 through 2013. The exposures were weight gain in early pregnancy (<22 weeks) and weight gain before diagnosis, standardized into gestational age-specific z scores. The outcome was GDM. We used logistic regression models with a generalized estimating equations method to estimate odds ratios with 95% confidence intervals for GDM, stratified by early-pregnancy body mass index (BMI) category. RESULTS Above average weight gain before diagnosis (z score >0) was associated with increased risk of GDM among all BMI groups except for obese III. Early gestational weight gain above average was associated with increased risk for GDM in overweight women. Below average weight gain before diagnosis (z score <0) was only associated with decreased risk of GDM in obese III. Early gestational weight gain below average was associated with reduced risks of GDM in obese class I, II, and III women. CONCLUSIONS The risk of GDM increased with higher weight gain before diagnosis in all BMI groups except obese class III, whereas the risk was reduced with lower weight gain before diagnosis in obese III women only. The risk of GDM increased with higher early gestational weight gain in overweight women, while the risk was reduced with lower early gestational weight gain among obese women. Obese women may benefit from lower weight gain, especially in early pregnancy.
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Affiliation(s)
- Huiling Xu
- Clinical Epidemiology Division, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - Jennifer A. Hutcheon
- Department of Obstetrics and GynecologyUniversity of British ColumbiaVancouverCanada
| | - Xingrong Liu
- Clinical Epidemiology Division, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine SolnaKarolinska InstitutetStockholmSweden,Department of Women's HealthKarolinska University HospitalStockholmSweden
| | - Sven Cnattingius
- Clinical Epidemiology Division, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - Elizabeth V. Arkema
- Clinical Epidemiology Division, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - Kari Johansson
- Clinical Epidemiology Division, Department of Medicine SolnaKarolinska InstitutetStockholmSweden,Department of Women's HealthKarolinska University HospitalStockholmSweden
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Muraca GM, Joseph K, Razaz N, Ladfors LV, Lisonkova S, Stephansson O. Crude and adjusted comparisons of cesarean delivery rates using the Robson classification: A population-based cohort study in Canada and Sweden, 2004 to 2016. PLoS Med 2022; 19:e1004077. [PMID: 35913981 PMCID: PMC9377587 DOI: 10.1371/journal.pmed.1004077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 08/15/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Robson classification has become a global standard for comparing and monitoring cesarean delivery (CD) rates across populations and over time; however, this classification does not account for differences in important maternal, fetal, and obstetric practice factors known to impact CD rates. The objectives of our study were to identify subgroups of women contributing to differences in the CD rate in Sweden and British Columbia (BC), Canada using the Robson classification and to estimate the contribution of maternal, fetal/infant, and obstetric practice factors to differences in CD rates between countries and over time. METHODS AND FINDINGS We conducted a population-based cohort study of deliveries in Sweden (January 1, 2004 to December 31, 2016; n = 1,392,779) and BC (March 1, 2004 to April 31, 2017; n = 559,205). Deliveries were stratified into Robson categories and the CD rate, relative size of each group and its contribution to the overall CD rate were compared between the Swedish and the Canadian cohorts. Poisson and log-binomial regression were used to assess the contribution of maternal, fetal, and obstetric practice factors to spatiotemporal differences in Robson group-specific CD rates between Sweden and BC. Nulliparous women comprised 44.8% of the study population, while women of advanced maternal age (≥35 years) and women with overweight/obesity (≥25 kg/m2) constituted 23.5% and 32.4% of the study population, respectively. The CD rate in Sweden was stable at approximately 17.0% from 2004 to 2016 (p for trend = 0.10), while the CD rate increased in BC from 29.4% to 33.9% (p for trend < 0.001). Differences in CD rates between Sweden and BC varied by Robson group, for example, in Group 1 (nullipara with a term, single, cephalic fetus with spontaneous labor), the CD rate was 8.1% in Sweden and 20.4% in BC (rate ratio [RR] for BC versus Sweden = 2.52, 95% confidence interval [CI] 2.49 to 2.56, p < 0.001) and in Group 2 (nullipara, single, cephalic fetus, term gestation with induction of labor or prelabor CD), the rate of CD was 37.3% in Sweden and 45.9% in BC (RR = 1.23, 95% CI 1.22 to 1.25, p < 0.001). The effect of adjustment for maternal characteristics (e.g., age, body mass index), maternal comorbidity (e.g., preeclampsia), fetal characteristics (e.g., head position), and obstetric practice factors (e.g., epidural) ranged from no effect (e.g., among breech deliveries; Groups 6 and 7) to explaining up to 5.2% of the absolute difference in the CD rate (Group 2: adjusted CD rate in BC 40.7%, adjusted RR = 1.09, 95% CI 1.08 to 1.12, p < 0.001). Adjustment also explained a substantial fraction of the temporal change in CD rates among some Robson groups in BC. Limitations of the study include a lack of information on intrapartum details, such as labor duration as well as maternal and perinatal outcomes associated with the observed differences in CD rates. CONCLUSIONS In this study, we found that several factors not included in the Robson classification explain a significant proportion of the spatiotemporal difference in CD rates in some Robson groups. These findings suggest that incorporating these factors into explanatory models using the Robson classification may be useful for ensuring that public health initiatives regarding CD rates are evidence informed.
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Affiliation(s)
- Giulia M. Muraca
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Ontario, Canada
- * E-mail:
| | - K.S. Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Neda Razaz
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
| | - Linnea V. Ladfors
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
- Division of Women’s Health, Department of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
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Bjonholm E, Soderholm S, Stephansson O, Askling H. Tick-borne encephalitis in pregnant women – a mini narrative review. New Microbes New Infect 2022; 48:101017. [PMID: 36176540 PMCID: PMC9513166 DOI: 10.1016/j.nmni.2022.101017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/20/2022] [Accepted: 08/19/2022] [Indexed: 11/28/2022] Open
Abstract
Tick-borne encephalitis (TBE) incidence has been increasing in Europe the last decades, but very few cases in pregnant women have been described. We present two cases and describe the serology of both mother and infant at the time of diagnosis and delivery, as well as at months 3, 6, 9, and 12 of follow-up. In both cases, pregnancies and infants developed normally. The mothers had moderate-to severe symptoms of TBE and were positive for IgM and IgG at the time of diagnosis, and throughout the follow up period whilst both infants were PCR- and IgM-negative and positive for IgG during their first months in life. Declining IgG titres were seen in the infants during follow-up until they became negative at the age of nine months. TBE IgG was vertically transmitted in these two cases of infants born to TBE-infected mothers.
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Affiliation(s)
- E. Bjonholm
- Department of Infectious Diseases, Mälarsjukhuset, Eskilstuna, Sweden
| | | | - O. Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - H.H. Askling
- Department of Medicine, Division of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden
- Corresponding author: Helena Hervius Askling, Institutionen för medicin Solna (MedS), Karolinska Universitetssjukhuset Solna NB6:02, 17176 Stockholm, Sweden.
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Razaz N, Muraca GM, Fink K, Boutin A, John S, Lisonkova S, Stephansson O, Cnattingius S, Joseph K. Time of delivery among low-risk women at 37-42 weeks of gestation and risks of stillbirth and infant mortality, and long-term neurological morbidity. Paediatr Perinat Epidemiol 2022; 36:577-587. [PMID: 35244233 PMCID: PMC9314589 DOI: 10.1111/ppe.12868] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/18/2022] [Accepted: 01/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The most important knowledge gap in connection with obstetric management for time of delivery in term low-risk pregnancies relates to the absence of information on long-term neurodevelopmental outcomes. OBJECTIVES We examined risks of stillbirth, infant mortality, cerebral palsy (CP) and epilepsy among low-risk pregnancies. METHODS In this population-based Swedish study, we identified, from 1998 to 2019, 1,773,269 singleton infants born between 37 and 42 completed weeks in women with low-risk pregnancies. Poisson log-linear regression models were used to examine the association between gestational age at delivery and stillbirth, infant mortality, CP and epilepsy. Adjusted rate ratios (RR) and 95% confidence intervals expressing the effect of birth at a particular gestational week compared with birth at a later gestational week were estimated. RESULTS Compared with those born at a later gestation, RRs for stillbirth and infant mortality were higher among births at 37 weeks' and 38 weeks' gestation. The RRs for infant mortality were approximately 20% and 25% lower among births at 40 or 41 weeks compared with those born at later gestation, respectively. Infants born at 37 and 38 weeks also had higher RRs for CP (vs infants born at ≥38 and ≥39 weeks, respectively), while those born at 39 gestation had similar RRs (vs infants born at ≥40 weeks); infants born at 40 and 41 weeks had lower RRs of CP (vs those born at ≥41 and 42 weeks, respectively). The RRs for epilepsy were higher in those born at 37 and 38 weeks compared with those born at later gestation. CONCLUSIONS Among low-risk pregnancies, birth at 37 or 38 completed weeks' gestation is associated with increased risks of stillbirth, infant mortality and neurological morbidity, while birth at 39-40 completed weeks is associated with reduced risks compared with births at later gestation.
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Affiliation(s)
- Neda Razaz
- Clinical Epidemiology DivisionDepartment of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - Giulia M. Muraca
- Clinical Epidemiology DivisionDepartment of Medicine SolnaKarolinska InstitutetStockholmSweden,Department of Obstetrics and GynaecologyBC Children’s and Women’s Hospital and Health Centre and the University of British ColumbiaVancouverBCCanada
| | - Katharina Fink
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Centrum for NeurologyAcademical Specialist CenterStockholmSweden
| | - Amélie Boutin
- Department of Obstetrics and GynaecologyBC Children’s and Women’s Hospital and Health Centre and the University of British ColumbiaVancouverBCCanada
| | - Sid John
- Department of Obstetrics and GynaecologyBC Children’s and Women’s Hospital and Health Centre and the University of British ColumbiaVancouverBCCanada
| | - Sarka Lisonkova
- Department of Obstetrics and GynaecologyBC Children’s and Women’s Hospital and Health Centre and the University of British ColumbiaVancouverBCCanada,School of Population and Public HealthUniversity of British ColumbiaVancouverBCCanada
| | - Olof Stephansson
- Clinical Epidemiology DivisionDepartment of Medicine SolnaKarolinska InstitutetStockholmSweden,Department of Women’s HealthKarolinska University HospitalStockholmSweden
| | - Sven Cnattingius
- Clinical Epidemiology DivisionDepartment of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - K. S. Joseph
- Department of Obstetrics and GynaecologyBC Children’s and Women’s Hospital and Health Centre and the University of British ColumbiaVancouverBCCanada,School of Population and Public HealthUniversity of British ColumbiaVancouverBCCanada
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47
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Ladfors LV, Muraca GM, Zetterqvist J, Butwick AJ, Stephansson O. Authors reply re: The Ten Group Classification System - First Things First. BJOG 2022; 129:1171-1173. [PMID: 34985182 DOI: 10.1111/1471-0528.17057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Linnea V Ladfors
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
| | - Giulia M Muraca
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynaecology and Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Johan Zetterqvist
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
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Morin M, Frisell T, Stephansson O, Hellgren K. OP0126 ARE WOMEN WITH SPONDYLOARTHRITIS AT INCREASED RISK OF ADVERSE MATERNAL AND INFANT OUTCOMES? – A SWEDISH COHORT STUDY. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundAn increased risk of adverse pregnancy and neonatal outcomes has been reported for pregnancies in women with several rheumatic diseases including rheumatoid arthritis and psoriatic arthritis. In spondyloarthritis (SpA), findings have not been uniform, with some studies reporting increased risks of Cesarean delivery, preterm birth, infants born small-for-gestational-age (SGA), and gestational diabetes- and hypertension, while others have failed to identify any significant differences between women with SpA and general population control women. Most studies reporting no differences have either been small or lacked an appropriate comparison group [1].ObjectivesTo assess the risk of adverse maternal and infant pregnancy outcomes in women with SpA compared to the general population.MethodsIn this nationwide register-based study, we included singleton births between April 2007 and December 2019 in women diagnosed with ankylosing spondylitis (AS; ICD-10 codes M45 or M08.1) or undifferentiated SpA (uSpA; ICD-10 codes M46.8 or M46.9). This was performed through linkage between the National Patient Register and the Medical Birth Register. Each birth was matched on birth year, maternal age, and parity to ten comparator births in women free from chronic inflammatory arthritis at time of birth. Relative risks (RR) of adverse outcomes were estimated by Poisson regression, adjusting for maternal country of birth, BMI, smoking in early pregnancy, educational level, and disposable income in the year before pregnancy.ResultsWomen with SpA (n=1394) were found to be at increased risk of several adverse outcomes compared to general population comparators (n=13932), as displayed in the Figure 1. Women with SpA had an increased risk of gestational diabetes (adjusted RR 1.88 [95% CI 1.10; 2.56]), elective and emergency Cesarean delivery (adjusted RR 1.54 [95% CI 1.32; 1.79] and 1.23 [95% CI 1.02; 1.48], respectively), and moderately preterm birth (adjusted RR 1.52 [95% CI 1.18; 1.97]). An association was seen with both spontaneous and medically indicated preterm birth, but the increase was only significant for spontaneous preterm birth. The risk estimate for preeclampsia was also increased, but failed to reach significance (adjusted RR 1.32 [95% CI 0.96; 1.81]). Infants to mothers with SpA were not more likely to be born SGA, but there was a slightly increased risk estimate of infection during their first year of life (adjusted RR 1.23 [95% CI 0.98; 1.53]).Figure 1.Number of events of adverse pregnancy outcomes among a nationwide cohort of births (n=1394) in Swedish women with SpA and comparator births (n=13932, matched 1:10 on birth year, maternal age, and parity). Relative risks from Poisson regression, adjusted for maternal country of birth, BMI, smoking in early pregnancy, educational level, and disposable income in the year before pregnancy.ConclusionWhile most pregnancies in women with SpA are uneventful, there is an increased risk for a number of adverse pregnancy outcomes. The increased risks for both emergency Cesarean delivery and spontaneous preterm birth suggest that these differences are not only driven by a different management of SpA pregnancies.References[1]Mokbel A, Lawson DO, Farrokhyar F. Pregnancy outcomes in women with ankylosing spondylitis: a scoping literature and methodological review. Clinical Rheumatology 2021;40(9):3465-80.Disclosure of InterestsNone declared
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Mitselou N, Stephansson O, Melén E, Ludvigsson JF. Exposure to Allergen-Specific Immunotherapy in Pregnancy and Risk of Congenital Malformations and Other Adverse Pregnancy Outcomes. J Allergy Clin Immunol Pract 2022; 10:1635-1641.e2. [PMID: 35487856 DOI: 10.1016/j.jaip.2022.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Owing to insufficient data, current guidelines recommend against initiating allergen-specific immunotherapy (AIT) during pregnancy but suggest that well-tolerated ongoing immunotherapy may be continued. OBJECTIVE To evaluate the safety of AIT in pregnancy, especially the risk for congenital malformations. METHODS This nationwide Swedish cohort study identified pregnancies exposed to AIT, both subcutaneous and sublingual, through the Swedish Medical Birth register and the Prescribed Drug Register between 2005 and 2014. Information on congenital malformations in offspring was retrieved from the National Patient Register. Using the personal identity number, we linked data between registers. Using logistic regression, we calculated odds ratios (ORs) with 95% CIs for congenital malformations and other adverse pregnancy outcomes after adjusting for potential confounders. RESULTS From 2005 to 2014, we identified 924,790 singleton pregnancies. Among these, 743 pregnancies had been exposed to AIT 3 months before conception up until gestational week 22. Allergen-specific immunotherapy in pregnancy was not linked to congenital malformations (OR = 0.90; 95% CI, 0.63-1.27) or other adverse pregnancy outcomes (preterm birth: OR = 0.98; 95% CI, 0.71-1.35; stillbirth: OR = 0.79; 95% CI, 0.26-2.47; or cesarean delivery: OR = 0.91; 95% CI, 0.76-1.09). Stratification by route of immunotherapy, subcutaneous or sublingual, resulted in similar ORs. Restricting the pregnancy cohort to women with asthma or pulmonary disease, nulliparous women, births in 2012 to 2014, or Swedish-born women yielded similar results. CONCLUSIONS This nationwide study found no evidence of congenital malformations or other adverse pregnancy outcomes in women treated with AIT in pregnancy.
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Affiliation(s)
- Niki Mitselou
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.
| | - Olof Stephansson
- Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden; Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Melén
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Science and Education Södersjukhuset, Stockholm, Sweden; Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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50
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Lundborg L, Åberg K, Sandström A, Liu X, Tilden E, Stephansson O, Ahlberg M. Association between first and second stage of labour duration and mode of delivery: A population-based cohort study. Paediatr Perinat Epidemiol 2022; 36:358-367. [PMID: 34964511 DOI: 10.1111/ppe.12848] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/23/2021] [Accepted: 11/28/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Active first stage of labour duration can widely vary between women. However, the nature of the relationship between the active first stage and second stage of labour duration is sparsely studied. OBJECTIVES To determine whether active first stage of labour duration (i) influences second stage of labour duration; and (ii) is associated with mode of delivery. METHODS A population-based cohort study of 13,379 women primiparous women, with spontaneous start in Stockholm-Gotland Region, Sweden, between 2008 and 2014. Duration of the active first stage of labour was examined in relation to second-stage duration using univariate and multivariable quantile regressions, with the first quartile (first stage duration) as the reference. Nonlinearity of associations was tested by restricted cubic splines. Association between active first-stage duration with mode of delivery was estimated using a multinomial logistic regression based on adjusted odds ratios. RESULTS Longer active first stage of labour duration was linearly associated with longer second stage of labour duration until approximately 12 h of active first stage of labour duration. After 12 h, a non-linear trend is seen, demonstrated by a plateau in the second-stage duration. In addition, longer active first stage of labour duration was associated with increased occurrence of operative vaginal delivery (adjusted odds ratio 3.36, 95% confidence interval [CI] 2.89, 3.89) and caesarean delivery (adjusted odds ratio 4.75, 95% CI 3.85, 5.80). CONCLUSIONS Among primiparous women with spontaneous onset of labour, longer active first stage of labour duration was associated with both longer second stage of labour duration and higher odds of operative delivery. This study contributes with findings, which may inform future discussions regarding how to properly account for second-stage duration, with applications in obstetric and perinatal epidemiology.
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Affiliation(s)
- Louise Lundborg
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Katarina Åberg
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anna Sandström
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women´s Health, Division of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Xingrong Liu
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ellen Tilden
- Department of Nurse-Midwifery, Oregon Health & Science University School of Nursing, Portland, OR, USA.,Department of Obstetrics and Gynecology, Oregon Health & Science University School of Medicine, Portland, OR, USA
| | - Olof Stephansson
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women´s Health, Division of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Mia Ahlberg
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Women´s Health, Division of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
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