Paper and electronic antenatal records: What do women and health care providers tell us about their use?

The antenatal paper hand-held record (PHR) has been used extensively in general practice (GP) shared-care management of pregnant women, but recently the antenatal electronic health record (EHR) was introduced. This study aimed to examine the experiences of women and health care providers who use the PHR and the EHR, and find out the relative role of these records in the integration of care. Purposive homogenous samples of women and health care providers were interviewed as users of the PHR in phase 1 and the EHR in phase 2 of the study. Qualitative data were collected via interview with women and GPs and focus groups held with hospital health care providers. Interviews were coded manually and analysed using qualitative content analysis. Fifteen women participated in phase 1 and 12 in phase 2. Seventeen GPs participated in phase 1 and 15 in phase 2. Five focus groups with hospital health care providers were conducted in each phase. Results were categorised into four themes: 1. Record purpose; 2. Perception of the record; 3. Content of the record, and; 4. Sharing information in the record. Both women and health care providers were familiar with the PHR, but identified that some information was missing or not utilised well, and reported underuse of the EHR. The study identified continued widespread use of the PHR and several issues concerning the use of the EHR. An improvement in the strategic implementation of the EHR is suggested as a mechanism to facilitate its wider adoption.

From maternity paper hand-held records to electronic health records: What do women tell us about their use?

The paper hand-held record (PHR) has been used extensively in general practice (GP) shared care management of pregnant women, and recently, the first Mater Shared Electronic Health Record (MSEHR) was introduced. The aim of this qualitative study was to examine women’s experiences using the records and the contribution of the records to integrate care. At the 36-week antenatal visit in a maternity tertiary centre clinic, women were identified as a user of either the PHR or the MSEHR and organised into Phase 1 and Phase 2 studies respectively. Fifteen women were interviewed in Phase 1 and 12 women in Phase 2. Semi-structured interviews were used for data collection, and analysed using qualitative content analysis. Four main themes were identified: (1) purpose of the record; (2) perceptions of the record; (3) content of the record, and; (4) sharing the record. Findings indicate that the PHR is a well-liked maternity tool. The findings also indicate there is under-usage of the MSEHR due to health-care providers failing to follow up and discuss the option of using the electronic health record option or if a woman has completed the log-in process. This paper adds to an already favourable body of knowledge about the use of the PHR. It is recommended that continued implementation of the MSEHR be undertaken to facilitate its use.

Diabetes in South Asians

Economic, dietary and other lifestyle transitions have been occurring rapidly in most South Asian countries, making their populations more vulnerable to developing Type 2 diabetes and cardiovascular diseases. Recent data show an increasing prevalence of Type 2 diabetes in urban areas as well as in semi-urban and rural areas, inclusive of people belonging to middle and low socio-economic strata. Prime determinants for Type 2 diabetes in South Asians include physical inactivity, imbalanced diets, abdominal obesity, excess hepatic fat and, possibly, adverse perinatal and early life nutrition and intra-country migration. It is reported that Type 2 diabetes affects South Asians a decade earlier and some complications, for example nephropathy, are more prevalent and progressive than in other races. Further, prevalence of pre-diabetes is high, and so is conversion to diabetes, while more than 50% of those who are affected remain undiagnosed. Attitudes, cultural differences and religious and social beliefs pose barriers in effective prevention and management of Type 2 diabetes in South Asians. Inadequate resources, insufficient healthcare budgets, lack of medical reimbursement and socio-economic factors contribute to the cost of diabetes management. The challenge is to develop new translational strategies, which are pragmatic, cost-effective and scalable and can be adopted by the South Asian countries with limited resources. The key areas that need focus are: generation of awareness, prioritizing health care for vulnerable subgroups (children, women, pregnant women and the underprivileged), screening of high-risk groups, maximum coverage of the population with essential medicines, and strengthening primary care. An effective national diabetes control programme in each South Asian country should be formulated, with these issues in mind.

Arterial stiffness and cardiovascular risk factors

Background: As the human body ages, the arteries gradually lose their elasticity and become stiffer. Although inevitable, this process is influenced by hereditary and environmental factors. Interestingly, many classic cardiovascular risk factors affect the arterial stiffness. During the last decade, accelerated arterial stiffening has been recognized as an important cardiovascular risk factor associated with increased mortality as well as with several chronic disorders. Objectives: This thesis examines the role of arterial stiffness in relation to variations in a physiological feature in healthy individuals. In addition, the effect on arterial stiffness of an acute transitory disease and the effect of a chronic disease are studied. Furthermore, the thesis analyzes the prognostic value of a marker of arterial stiffness in individuals with chronic disease. Finally, a potential method of reducing arterial stiffness is evaluated. Material and study design: The first study examines pulse wave reflection and pulse wave velocity in relation to muscle fibre distribution in healthy middle-aged men. In the second study, pulse wave reflection in women with current or previous preeclampsia is compared to a healthy control group. The effect of aging on the different blood pressure indices in patients with type 1 diabetes is examined in the third study, whereas the fourth paper studies the relation between these blood pressure indices and mortality in type 2 diabetes. The fifth study evaluates how intake of a fermented milk product containing bioactive peptides affects pulse wave reflection in individuals with mild hypertension. Results and conclusions: Muscle fibre type distribution is not an independent determinant of arterial stiffness in middle-aged males. Pulse wave reflection is increased in pregnant women with preeclampsia, but not in previously preeclamptic non-pregnant women. Patients with type 1 diabetes have a higher and more rapidly increasing pulse pressure, which suggests accelerated arterial stiffening. In elderly type 2 diabetic patients, very high and very low levels of pulse pressure are associated with higher mortality. Intake of milk-derived bioactive peptides reduces pulse wave reflection in hypertensive males but not in hypertensive females.

A Safe Vaccine (DV-STM-07) against Salmonella Infection Prevents Abortion and Confers Protective Immunity to the Pregnant and New Born Mice

Pregnancy is a transient immuno-compromised condition which has evolved to avoid the immune rejection of the fetus by the maternal immune system. The altered immune response of the pregnant female leads to increased susceptibility to invading pathogens, resulting in abortion and congenital defects of the fetus and a subnormal response to vaccination. Active vaccination during pregnancy may lead to abortion induced by heightened cell mediated immune response. In this study, we have administered the highly attenuated vaccine strain delta pmrG-HM-D (DV-STM-07) in female mice before the onset of pregnancy and followed the immune reaction against challenge with virulent S. Typhimurium in pregnant mice. Here we demonstrate that DV-STM-07 vaccine gives protection against Salmonella in pregnant mice and also prevents Salmonella induced abortion. This protection is conferred by directing the immune response towards Th2 activation and Th1 suppression. The low Th1 response prevents abortion. The use of live attenuated vaccine just before pregnancy carries the risk of transmission to the fetus. We have shown that this vaccine is safe as the vaccine strain is quickly eliminated from the mother and is not transmitted to the fetus. This vaccine also confers immunity to the new born mice of vaccinated mothers. Since there is no evidence of the vaccine candidate reaching the new born mice, we hypothesize that it may be due to trans-colostral transfer of protective anti-Salmonella antibodies. These results suggest that our vaccine DV-STM-07 can be very useful in preventing abortion in the pregnant individuals and confer immunity to the new born. Since there are no such vaccine candidates which can be given to the new born and to the pregnant women, this vaccine holds a very bright future to combat Salmonella induced pregnancy loss.

Factor V Leiden as risk factor for pregnancy complications : Epidemiological study of Finnish women

Factor V Leiden (FV Leiden) is the most common inherited thrombophilia in Caucasians increasing the risk for venous thrombosis. Its prevalence in Finland is 2-3%. FV Leiden has also been associated with several pregnancy complications. However, the importance of FV Leiden as their risk factor is unclear. The aim of the study was to assess FV Leiden as a risk factor for pregnancy complications in which prothrombotic mechanisms may play a part. Specifically, the study aimed to assess the magnitude of the risk, if any, associated with FV Leiden for pregnancy-associated venous thrombosis, pre-eclampsia, unexplained stillbirth, and preterm birth. The study was conducted as a nested case-control study within a fixed cohort of 100,000 consecutive pregnant women in Finland. The study was approved by the ethics committee of the Finnish Red Cross Blood Service and by the Ministry of Social Affairs and Health. All participants gave written informed consent. Cases and controls were identified by using national registers. The diagnoses of the 100,000 women identified from the National Register of Blood Group and Blood Group Antibodies of Pregnant Women were obtained from the National Hospital Discharge Register. Participants gave blood samples for DNA tests and filled in questionnaires. The medical records of the participants were reviewed in 49 maternity hospitals in Finland. Genotyping was performed in the Finnish Genome Center. When evaluating pregnancy-associated venous thrombosis (34 cases, 641 controls), FV Leiden was associated with 11-fold risk (OR 11.6, 95% CI 3.6-33.6). When only analyzing women with first venous thrombosis, the risk was 6-fold (OR 5.8, 95% CI 1.6-21.8). The risk was increased by common risk factors, the risk being highest in women with FV Leiden and pre-pregnancy BMI over 30 kg/m2 (75-fold), and in women with FV Leiden and age over 35 years (60-fold). When evaluating pre-eclampsia (248 cases, 679 controls), FV Leiden was associated with a trend of increased risk (OR 1.7, 95% CI 0.8-3.9), but the association was not statistically significant. When evaluating unexplained stillbirth (44 cases, 776 controls), FV Leiden was associated with over 3-fold risk (OR 3.8, 95% CI 1.2-11.6). When evaluating preterm birth (324 cases, 752 controls), FV Leiden was associated with over 2-fold risk (OR 2.4, 95% CI 1.3-4.6). FV Leiden was especially associated with late preterm birth (32-36 weeks of gestation), but not with early preterm birth (< 32 weeks of gestation). The results of this large population-based study can be generalized to Finnish women with pregnancies continuing beyond first trimester, and may be applied to Caucasian women in populations with similar prevalence of FV Leiden and high standard prenatal care.

Prenatal protease inhibitor use and risk of preterm birth among HIV-infected women initiating antiretroviral drugs during pregnancy.

BACKGROUND: Conflicting results have been reported among studies of protease inhibitor (PI) use during pregnancy and preterm birth. Uncontrolled confounding by indication may explain some of the differences among studies. METHODS: In total, 777 human immunodeficiency virus (HIV)-infected pregnant women in a prospective cohort who were not receiving antiretroviral (ARV) treatment at conception were studied. Births <37 weeks gestation were reviewed, and deliveries due to spontaneous labor and/or rupture of membranes were identified. Risk of preterm birth and low birth weight (<2500 g) were evaluated by using multivariable logistic regression. RESULTS: Of the study population, 558 (72%) received combination ARV with PI during pregnancy, and a total of 130 preterm births were observed. In adjusted analyses, combination ARV with PI was not significantly associated with spontaneous preterm birth, compared to ARV without PI (odds ratio [OR], 1.22; 95% confidence interval [CI], 0.70-2.12). Sensitivity analyses that included women who received ARV prior to pregnancy also did not identify a significant association (OR, 1.34; 95% CI, 0.84-2.16). Low birth weight results were similar. CONCLUSIONS: No evidence of an association between use of combination ARV with PI during pregnancy and preterm birth was found. Our study supports current guidelines that promote consideration of combination ARV for all HIV-infected pregnant women.

Pregnancy, alcohol intake, and intimate partner violence among men and women attending drinking establishments in a Cape Town, South Africa township.

The highest rates of fetal alcohol syndrome worldwide can be found in South Africa. Particularly in impoverished townships in the Western Cape, pregnant women live in environments where alcohol intake during pregnancy has become normalized and interpersonal violence (IPV) is reported at high rates. For the current study we sought to examine how pregnancy, for both men and women, is related to alcohol use behaviors and IPV. We surveyed 2,120 men and women attending drinking establishments in a township located in the Western Cape of South Africa. Among women 13.3% reported being pregnant, and among men 12.0% reported their partner pregnant. For pregnant women, 61% reported attending the bar that evening to drink alcohol and 26% reported both alcohol use and currently experiencing IPV. Daily or almost daily binge drinking was reported twice as often among pregnant women than non-pregnant women (8.4% vs. 4.2%). Men with pregnant partners reported the highest rates of hitting sex partners, forcing a partner to have sex, and being forced to have sex. High rates of alcohol frequency, consumption, binge drinking, consumption and binge drinking were reported across the entire sample. In general, experiencing and perpetrating IPV were associated with alcohol use among all participants except for men with pregnant partners. Alcohol use among pregnant women attending shebeens is alarmingly high. Moreover, alcohol use appears to be an important factor in understanding the relationship between IPV and pregnancy. Intensive, targeted, and effective interventions for both men and women are urgently needed to address high rates of drinking alcohol among pregnant women who attend drinking establishments.

Homocysteine is lower in the Third Trimester of Pregnancy in Women with Enhanced Folate status from continued Folic Acid Supplementation.

Background: In many countries current recommendations are that women take a daily 400ug folic acid supplement, from before conception until the end of the 12th week of gestation, for the prevention of neural tube defects. Low folate status is associated with an elevated concentration of plasma total homocysteine (tHcy), a risk factor that is associated with pregnancy complications such as pre-eclampsia. Methods: In a longitudinal study, tHcy and corresponding folate status were determined in 101 pregnant women at 12, 20 and 35 weeks of gestation, in 35 non-pregnant control subjects sampled conconcurrently, and in a subgroup (n=21 pregnant, 19 non-pregnant women) at 3 days post-partum. Results: Plasma tHcy concentrations were significantly lower throughout pregnancy compared with control subjects, with values lowest in the 2nd trimester before increasing toward non-pregnant values in the 3rd trimester. Importantly, tHcy concentrations were lower in pregnant women taking folic acid supplements compared to those not, an effect which reached significance in the 3rd trimester (5.25 umol/l v 6.89 umol/l, P <0.05). Furthermore, during the 3rd trimester, tHcy concentrations were significantly higher in pregnant women with a history of miscarriage compared to those with no previous history (7.32 umol/l v 5.62 u­mol/l, P <0.01). Conclusion: This is the first longitudinal study to show that homocysteine levels rise in late pregnancy towards non-pregnant levels; a rise which can be limited by enhancing folate status through continued folic acid supplementation. These results indicate a potential role for continued folic acid supplementation in reducing pregnancy complications associated with hyperhomocysteinaemia.

Serum Inflammatory Markers and Preeclampsia in Type 1 Diabetes:A prospective study

OBJECTIVE Inflammation and endothelial dysfunction have been associated with the immunobiology of preeclampsia (PE), a significant cause of adverse pregnancy outcomes. The prevalence of PE is elevated several fold in the presence of maternal type 1 diabetes mellitus (T1DM). Although cross-sectional studies of pregnancies among women without diabetes have shown altered inflammatory markers in the presence of PE, longitudinal studies of diabetic women are lacking. In maternal serum samples, we examined the temporal associations of markers of inflammation with the subsequent development of PE in women with T1DM. RESEARCH DESIGN AND METHODS We conducted longitudinal analyses of serum C-reactive protein (CRP), adhesion molecules, and cytokines during the first (mean ± SD, 12.2 ± 1.9 weeks), second (21.6 ± 1.5 weeks), and third (31.5 ± 1.7 weeks) trimesters of pregnancy (visits 1-3, respectively). All study visits took place before the onset of PE. Covariates were BMI, HbA1c, age of onset, duration of diabetes, and mean arterial pressure. RESULTS In women with T1DM who developed PE versus those who remained normotensive, CRP tended to be higher at visits 1 (P = 0.07) and 2 (P = 0.06) and was significantly higher at visit 3 (P <0.05); soluble E-selectin and interferon-?-inducible protein-10 (IP-10) were significantly higher at visit 3; interleukin-1 receptor antagonist (IL-1ra) and eotaxin were higher and lower, respectively, at visit 2 (all P <0.05). These conclusions persisted following adjustment for covariates. CONCLUSIONS In pregnant women with T1DM, elevated CRP, soluble E-selectin, IL-1ra, and IP-10 and lower eotaxin were associated with subsequent PE. The role of inflammatory factors as markers and potential mechanisms of the high prevalence of PE in T1DM merits further investigation.

Plasma Lipoproteins and Preeclampsia in Women with Type 1 Diabetes: A Prospective Study

Context: In nondiabetic pregnancy, cross-sectional studies have shown associations between maternal dyslipidemia and preeclampsia (PE). In type 1 diabetes mellitus (T1DM), the prevalence of PE is increased 4-fold, but prospective associations with plasma lipoproteins are unknown.

Objectives: The aim of this study was to define lipoprotein-related markers and potential mechanisms for PE in T1DM.

Design and Settings: We conducted a multicenter prospective study in T1DM pregnancy.

Patients: We studied 118 T1DM women (26 developed PE, 92 remained normotensive). Subjects were studied at three visits before PE onset [12.2 1.9, 21.6 1.5, and 31.5 1.7 wk gestation (means SD)] and at term (37.6 2.0 wk). Nondiabetic normotensive pregnant women (n 21) were included for reference.

Main Outcome Measures: Conventional lipid profiles, lipoprotein subclasses [defined by size (nuclear magnetic resonance) and by apolipoprotein content], serum apolipoproteins (ApoAI, ApoB, and ApoCIII), and lipolysis (ApoCIII ratio) were measured in T1DM women with and without subsequent PE.

Results: In women with vs. without subsequent PE, at the first and/or second study visits: lowdensity lipoprotein (LDL)-cholesterol, particle concentrations of total LDL and large (but not small) LDL, serum ApoB, and ApoB:ApoAI ratio were all increased (P 0.05); peripheral lipoprotein lipolysis was decreased (P0.01). These early differences remained significant in covariate analysis (glycated hemoglobin, actual prandial status, gravidity, body mass index, and diabetes duration) but were not present at the third study visit. High-density lipoprotein and very low-density lipoprotein subclasses did not differ between groups before PE onset.

Conclusions: Early in pregnancy, increased cholesterol-rich lipoproteins and an index suggesting decreased peripheral lipolysis were associated with subsequent PE in T1DM women. Background maternal lipoprotein characteristics, perhaps masked by effects of late pregnancy, may influence PE risk.

Glycemic targets in the second and third trimester of pregnancy for women with type 1 diabetes

OBJECTIVE: To assess the relationship between second and third trimester glycemic control and adverse outcomes in pregnant women with type 1 diabetes, as uncertainty exists about optimum glycemic targets.

RESEARCH DESIGN AND METHODS: Pregnancy outcomes were assessed prospectively in 725 women with type 1 diabetes from the Diabetes and Pre-eclampsia Intervention Trial. HbA1c (A1C) values at 26 and 34 weeks' gestation were categorized into five groups, the lowest, <6.0% (42 mmol/mol), being the reference. Average pre- and postprandial results from an eight-point capillary glucose profile the previous day were categorized into five groups, the lowest (preprandial <5.0 mmol/L and postprandial <6.0 mmol/L) being the reference.

RESULTS: An A1C of 6.0-6.4% (42-47 mmol/mol) at 26 weeks' gestation was associated with a significantly increased risk of large for gestational age (LGA) (odds ratio 1.7 [95% CI 1.0-3.0]) and an A1C of 6.5-6.9% (48-52 mmol/mol) with a significantly increased risk of preterm delivery (odds ratio 2.5 [95% CI 1.3-4.8]), pre-eclampsia (4.3 [1.7-10.8]), need for a neonatal glucose infusion (2.9 [1.5-5.6]), and a composite adverse outcome (3.2 [1.3-8.0]). These risks increased progressively with increasing A1C. Results were similar at 34 weeks' gestation. Glucose data showed less consistent trends, although the risk of a composite adverse outcome increased with preprandial glucose levels between 6.0 and 6.9 mmol/L at 34 weeks (3.3 [1.3-8.0]).

CONCLUSIONS: LGA increased significantly with an A1C ≥6.0 (42 mmol/mol) at 26 and 34 weeks' gestation and with other adverse outcomes with an A1C ≥6.5% (48 mmol/mol). The data suggest that there is clinical utility in regular measurement of A1C during pregnancy.

Analgesic exposure in pregnant rats affects fetal germ cell development with inter-generational reproductive consequences

Analgesics which affect prostaglandin (PG) pathways are used by most pregnant women. As germ cells (GC) undergo developmental and epigenetic changes in fetal life and are PG targets, we investigated if exposure of pregnant rats to analgesics (indomethacin or acetaminophen) affected GC development and reproductive function in resulting offspring (F1) or in the F2 generation. Exposure to either analgesic reduced F1 fetal GC number in both sexes and altered the tempo of fetal GC development sex-dependently, with delayed meiotic entry in oogonia but accelerated GC differentiation in males. These effects persisted in adult F1 females as reduced ovarian and litter size, whereas F1 males recovered normal GC numbers and fertility by adulthood. F2 offspring deriving from an analgesic-exposed F1 parent also exhibited sex-specific changes. F2 males exhibited normal reproductive development whereas F2 females had smaller ovaries and reduced follicle numbers during puberty/adulthood; as similar changes were found for F2 offspring of analgesic-exposed F1 fathers or mothers, we interpret this as potentially indicating an analgesic-induced change to GC in F1. Assuming our results are translatable to humans, they raise concerns that analgesic use in pregnancy could potentially affect fertility of resulting daughters and grand-daughters.

Women's Attachment as a Predictor of Pain During Labour and Post-Delivery: a Prospective Observational Study

INTRODUCTION: Labour is considered to be one of the most painful and significant experiences in a woman's life. The aim of this study was to examine whether women's attachment style is a predictor of the pain experienced throughout labour and post-delivery. MATERIAL AND METHODS:Thirty-two pregnant women were assessed during the third trimester of pregnancy and during labour. Adult attachment was assessed with the Adult Attachment Scale ' Revised. The perceived intensity of labour pain was measured using a visual analogue scale for pain in the early stage of labour, throughout labour and post-delivery. RESULTS:Women with an insecure attachment style reported more pain at 3 cm of cervical dilatation (p < 0.05), before the administration of analgesia (p < 0.01) and post-delivery (p < 0.05) than those securely attached. In multivariate models, attachment style was a significant predictor of labour pain at 3 cm of cervical dilatation and before the first administration of analgesia but not of the perceived pain post-delivery. DISCUSSION: These findings confirm that labour pain is influenced by relevant psychological factors and suggest that a woman's attachment style may be a risk factor for greater pain during labour. CONCLUSION:Future studies in the context of obstetric pain may consider the attachment style as an indicator of individual differences in the pain response during labour. This may have important implications in anaesthesiology and to promote a relevant shift in institutional practices and therapeutic procedures.

The association between maternity insurance, residence status and selected perinatal outcomes among Chinese women

Objective: To investigate the impact of maternity insurance and maternal residence on birth outcomes in a Chinese population. Methods: Secondary data was analyzed from a perinatal cohort study conducted in the Beichen District of the city of Tianjin, China. A total of 2364 pregnant women participated in this study at approximately 12-week gestation upon registration for receiving prenatal care services. After accounting for missing information for relevant variables, a total of 2309 women with single birth were included in this analysis. Results: A total of 1190 (51.5%) women reported having maternity insurance, and 629 (27.2%) were rural residents. The abnormal birth outcomes were small for gestational age (SGA, n=217 (9.4%)), large for gestational age (LGA, n=248 (10.7%)), birth defect (n=48 (2.1%)) including congenital heart defect (n=32 (1.4%)). In urban areas, having maternal insurance increased the odds of SGA infants (1.32, 95%CI (0.85, 2.04), NS), but decreased the odds of LGA infants (0.92, 95%CI (0.62, 1.36), NS); also decreased the odds of birth defect (0.93, 95%CI (0.37, 2.33), NS), and congenital heart defect (0.65, 95%CI (0.21, 1.99), NS) after adjustment for covariates. In contrast to urban areas, having maternal insurance in rural areas reduced the odds of SGA infants (0.60, 95%CI (0.13, 2.73), NS); but increased the odds of LGA infants (2.16, 95%CI (0.92, 5.04), NS), birth defects (2.48, 95% CI (0.70, 8.80), NS), and congenital heart defect (2.18, 95%CI (0.48, 10.00), NS) after adjustment for the same covariates. Similar results were obtained from Bootstrap methods except that the odds ratio of LGA infants in rural areas for maternal insurance was significant (95%CI (1.13, 4.37)); urban residence was significantly related with lower odds of birth defect (95%CI (0.23, 0.89)) and congenital heart defect (95%CI (0.19, 0.91)). Conclusions: whether having maternal insurance did have an impact on perinatal outcomes, but the impact of maternal insurance on the perinatal outcomes showed differently between women with urban residence and women with rural residence status. However, it is not clear what are the reason causing the observed differences. Thus, more studies are needed.