Psychosocial impact of high-risk pregnancy: hospital and home care

Signs or symptoms of suspected preeclampsia - A retrospective national database study of prevalence, costs, and outcomes

BACKGROUND

Most patients with signs or symptoms (s/s) of suspected preeclampsia are not diagnosed with preeclampsia. We sought to determine and compare the prevalence of s/s, pregnancy outcomes, and costs between patients with and without diagnosed preeclampsia.

METHODS

This retrospective cohort study analyzed a large insurance research database. Pregnancies with s/s of preeclampsia versus a confirmed preeclampsia diagnosis were identified using International Classification of Diseases codes. S/s include hypertension, proteinuria, headache, visual symptoms, edema, abdominal pain, and nausea/vomiting. Pregnancies were classed as 1) s/s of preeclampsia without a confirmed preeclampsia diagnosis (suspicion only), 2) s/s with a confirmed diagnosis (preeclampsia with suspicion), 3) diagnosed preeclampsia without s/s recorded (preeclampsia only), and 4) no s/s, nor preeclampsia diagnosis (control).

RESULTS

Of 1,324,424 pregnancies, 29.2 % had ≥1 documented s/s of suspected preeclampsia, and 14.2 % received a preeclampsia diagnosis. Hypertension and headache were the most common s/s, leading 20.2 % and 9.2 % pregnancies developed to preeclampsia diagnosis, respectively. Preeclampsia, with or without suspicion, had the highest rates of hypertension-related severe maternal morbidity (HR [95 % CI]: 3.0 [2.7, 3.2] and 3.6 [3.3, 4.0], respectively) versus controls. A similar trend was seen in neonatal outcomes such as preterm delivery and low birth weight. Cases in which preeclampsia was suspected but not confirmed had the highest average total maternal care costs ($6096 [95 % CI: 602, 6170] over control).

CONCLUSION

There is a high prevalence but poor selectivity of traditional s/s of preeclampsia, highlighting a clinical need for improved screening method and cost-effectiveness disease management.

Statement of the Obstetrics and Prenatal Medicine Working Group (AGG - Preterm Birth Section) on "Outpatient Management for Pregnant Women with Preterm Premature Rupture of Membranes (PPROM)"

Preterm premature rupture of membranes (PPROM) is one of the leading causes of perinatal morbidity and mortality. After a PPROM, more than 50% of pregnant women are delivered within 7 days. Fetal and maternal risks are primarily due to infection and inflammation, placental abruption, umbilical cord complications and preterm birth. Standard care usually consists of an expectant approach. Management includes the administration of antenatal steroids and antibiotic therapy. Patients with PPROM require close monitoring. The management of pregnant women with PPROM (inpatient vs. outpatient) is still the subject of controversial debate. The international guidelines also do not offer a clear stance. The statement presented here discusses the current state of knowledge.

Prenatal paternal depression, anxiety, and somatic symptom burden in different risk samples: an explorative study

PURPOSE

Growing evidence implies that transition to parenthood triggers symptoms of mental burden not only in women but likewise in men, especially in high-risk pregnancies. This is the first study that examined and compared the prevalence rates of depression, anxiety, and somatic symptom burden of expectant fathers who face different risk situations during pregnancy.

METHODS

Prevalence rates of paternal depression (Edinburgh postnatal depression scale), anxiety (generalized anxiety disorder seven), and somatic symptom burden (somatic symptom scale eight) were examined in two risk samples and one control group in the third trimester of their partners' pregnancy: risk sample I (n = 41) consist of expectant fathers whose partners were prenatally hospitalized due to medical complications; risk sample II (n = 52) are fathers whose partners were prenatally mentally distressed; and control group (n = 70) are those non-risk pregnancies.

RESULTS

On a purely descriptive level, the data display a trend of higher symptom burden of depression, anxiety, and somatic symptoms in the two risk samples, indicating that expectant fathers, whose pregnant partners were hospitalized or suffered prenatal depression, were more prenatally distressed. Exploratory testing of group differences revealed an almost three times higher prevalence rate of anxiety in fathers whose partner was hospitalized (12.2%) compared to those non-risks (4.3%).

CONCLUSION

Results underline the need for screening implementations for paternal prenatal psychological distress, as well as specific prevention and treatment programs, especially for fathers in risk situations, such as their pregnant partners' prenatal hospitalization. The study was registered with the German clinical trials register (DRKS00020131) on 2019/12/09.

Acceptance, experiences, and needs of hospitalized pregnant women toward an electronic mindfulness-based intervention: A pilot mixed-methods study

BACKGROUND

Anxiety disorders and depression during pregnancy are highly prevalent. Hospitalized pregnant women with high maternal or fetal risk represent a particularly vulnerable population often excluded from research samples. Screening for mental health disorders is not routinely offered for this particular patient group. Electronic mindfulness-based interventions constitute an accessible, convenient, and cost-effective mental health resource but have not yet been evaluated for acceptance in inpatient settings. To date, little is known about the needs and perceptions of this group of women.

OBJECTIVE

The aim of this study was to examine whether a brief electronic mindfulness-based intervention (eMBI) is accepted among hospitalized high-risk pregnant women. We assessed personal motivation and barriers, experiences, usability requirements, and overall acceptance of the eMBI, as well the specific needs and demands of patients with high-risk pregnancies regarding mental health services.

METHODS

An exploratory pilot study with a mixed-methods study design was carried out among 30 women hospitalized with a high obstetric risk. The study participants were given access to an eMBI with a 1-week mindfulness program on how to deal with stress, anxiety, and depressive symptoms. Semi-structured interviews were conducted with the 30 participants and analyzed using systematic content analysis. In addition, acceptance and usability were assessed via questionnaires.

RESULTS

Study findings showed a high level of acceptance of the eMBI. Most of the respondents were satisfied with the usability and considered the eMBI program to be helpful. The greatest barriers to using the eMBI were a general negative attitude toward using apps, preference for personal contact, or no current need for psychotherapy. Participants criticized the lack of awareness of mental health issues during pregnancy and expressed a need for low-threshold treatment offers, especially during hospitalization.

CONCLUSIONS

There is a strong need for mental health services in pregnancy care, especially for pregnant women with risk profiles. An eMBI offers an acceptable means of providing mental health support for hospitalized women with a severe obstetric risk.

Dramatically altered environmental lighting conditions in women with high-risk pregnancy during hospitalization

The maternal circadian time structure is incredibly important in the entrainment and programing of the fetal and newborn circadian time structure. Natural sunlight is the primary environmental time cue for entrainment of circadian rhythms, but high-risk pregnant women spend most of their time indoors with artificial light sources and extremely low levels of natural light both during the day and night. Because the daily level, timing, duration of light exposure and its spectral properties are important in maintaining the normal circadian physiology in humans, we aimed to evaluate the environmental lighting conditions in high-risk pregnant women admitted to hospital for long-term stay. About 30 patients were included in the study. Exposed illuminance, color temperature and effective circadian radiation dose were measured and recorded every 10 s by light dosimeters attached to the patients' clothing. We documented the illuminance of 29 pregnant women on 235 inpatient days. Median (IQR) measured illuminance was 70 (28-173) lux in the morning, 124 (63-241) lux in the afternoon, 19 (6-53) lux in the evening and 0 (0-0) lux at the night. Median illuminance for the 235 inpatient days of assessment was below the recommended EU standard of 100 lux-60.5% of the mornings and 42.7% of the afternoons. The women confined to indoor locations rarely achieved an illuminances more than 300 lux in the morning and in the afternoon. Compared to women with outdoor mobility, those confined indoors have a significantly lower illuminance and color temperature, both in the morning and in the afternoon. Our study presents the first information about the dramatically altered environmental lighting conditions experienced by high-risk pregnant women during their hospital stay. Their exposure to light while in the hospital is significantly lower than exposure to natural daylight levels and below the recommended EU standard.

Selected predictors of maternal-fetal attachment in pregnancies with congenital disorders, other complications, and in healthy pregnancies

BACKGROUND

The mother-infant attachment begins to form during pregnancy and is important for the future development of the child. Pregnancy complications can affect this relationship. The purpose of the study was to identify predictors of maternal-fetal attachment in physiological and high-risk pregnancies.

PARTICIPANTS AND PROCEDURE

The study group included women in pregnancies with congenital disorders (n = 65) or with other pregnancy complications (n = 65). A third group included women in healthy pregnancies (n = 65). Data were collected by: the Maternal-Fetal Attachment Scale, the Questionnaire of Attachment Styles, the Rosenberg Self-Esteem Scale, the State-Trait Anxiety Inventory, the Social Support Scale, a standardized interview, the Dependency on Intimate Partner Scale, and the Pregnancy Experiences Scale.

RESULTS

No significant differences in maternal-fetal attachment (MFA) were found between the groups. No predictors of MFA were observed for the women with a pregnancy with a congenital disorder. In the group of pregnancies with other complications, the only predictor of attachment intensity was pregnancy experience: a more negative attitude toward pregnancy was associated with lower MFA. In physiological pregnancies, MFA was found to be determined by pregnancy experience, gestational age, maternal age and dependency on one's intimate partner. MFA increased as pregnancy progressed. Younger mothers in physiological pregnancies, who have more positive pregnancy experiences and are less dependent on a partner, achieve higher levels of MFA.

CONCLUSIONS

The presence of high-risk pregnancy, or its absence, does not differentiate the intensity of the emotional bond between mother and fetus. However, women with healthy pregnancies demonstrate different predictors of MFA than those with high-risk pregnancies.

Preterm premature rupture of membranes: Which criteria contraindicate home care management?

INTRODUCTION

Home care management offers a suitable alternative to hospitalization for management of preterm premature rupture of membranes (PPROM). Eligibility criteria have not been clearly established. Our aim was to determine predictive factors of complication during home care management of PPROM in order to define optimal eligibility criteria.

MATERIAL AND METHODS

Retrospective cohort study of all women with singleton pregnancies with PPROM managed as outpatients between 2009 and 2015. Complications were defined as the occurrence of one of these events: fetal death, placental abruption, umbilical cord prolapse, delivery outside maternity hospital, neonatal death.

RESULTS

In all, 187 women with PPROMs were managed as outpatients, of whom 12 had a complication (6.4%). In the "complication" group, gestational age at diagnosis (P = 0.006) and at delivery (P < 0.001) were lower, with no difference in latency between these two events. Three criteria significantly increased the risk for a severe complication: PPROM occurring before 26 weeks (P = 0.008), non-cephalic fetal presentation (P = 0.02) and oligoamnios (P = 0.02). When unfavorable criteria were associated with PPROM, the risk was increased (1 criterion, odds ratio [OR] 1.6; 2 criteria, OR 6.9 and 3 criteria, OR 32.8).

CONCLUSIONS

Combination of these three criteria is an indication for conventional hospitalization to limit maternal and fetal morbidity. When two criteria are combined, home care should be discussed for each case. If only one unfavorable criteria is present, outpatient management is suitable. To validate these results, a prospective randomized study should be conducted.

Social support received by women with intellectual and developmental disabilities during pregnancy and childbirth: An exploratory qualitative study

OBJECTIVE

this study aims to contribute to the development of a conceptual framework that will inform maternity care improvements for expectant mothers with intellectual and developmental disabilities (IDD) by exploring the structure, functions, and perceived quality of social support received by women with IDD during pregnancy and childbirth.

DESIGN/SETTING

using a grounded theory approach, we conducted an exploratory study set in Ontario, Canada in 2015.

PARTICIPANTS

the sample included four adult women with IDD who had given birth in the last five years.

MEASUREMENTS

data were collected using semi-structured interviews.

FINDINGS

the structure of social support received by women with IDD consisted of both formal and informal sources, but few or no friendships. Women with IDD reported high levels of informational and instrumental support and low levels of emotional support and social companionship. However, a high level of available support was not always perceived as beneficial. Emergent core categories suggest that social support is perceived as most effective when three conditions are met: (1) support is accessible, (2) support is provided by individuals expressing positive attitudes towards the pregnancy, and (3) autonomy is valued.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

our study confirms and identifies important gaps in the social support received by expectant mothers with IDD. Women with IDD currently lack accessible informational support, emotional support, and social companionship during pregnancy and childbirth. Additional findings regarding the structure and functions of social support are presented, and a preliminary conceptual framework of effective social support during pregnancy and childbirth, as perceived by women with IDD is also proposed. Findings suggest that increasing support accessibility should be a social and clinical priority; however, maternity care providers should be aware of stigmatizing attitudes and respect the autonomy of pregnant women with IDD as they prepare for motherhood.

The support needs of high-risk antenatal patients in prolonged hospitalisation

OBJECTIVE

to identify and describe the support needs of high-risk antenatal patients hospitalised for more than five days.

DESIGN

a qualitative, explorative and descriptive design. In-depth interviews were conducted with pregnant women during their stay in hospital until data saturation was reached.

SETTING

an antenatal unit in a private hospital in Gauteng Province, South Africa.

PARTICIPANTS

11 antepartum women who had been hospitalised for five days or more and were of any gestation period.

FINDINGS

three main themes emerged: (a) a need for social support; (b) improvement of the environment; and (c) assistance with emotional adaptation and acceptance of prolonged hospitalisation.

KEY CONCLUSION

prolonged hospitalisation of high-risk antenatal patients disrupts the usual adaptation to pregnancy. These patients develop specific needs during hospitalisation. Findings suggest that the length of hospitalisation influences the specific support needs of antenatal patients.

IMPLICATIONS FOR PRACTICE

this study identified a link between social and environmental support, emotional adaptation, acceptance of hospitalisation of high-risk antenatal patients and improvement of their health status. Through reflection on these themes, recommendations can be made and strategies implemented to meet the support needs of high-risk antenatal patients.

While You Are Waiting: a family-focused antepartum support program

While You Are Waiting is an antepartum support program developed for hospitalized, high-risk pregnant women. The goal of the program is to provide an atmosphere for the mother that will minimize the adverse effects of long-term activity restrictions and prolonged hospitalization. The program focuses on 4 key opportunities to promote optimal outcomes: education, support, recreation, and outreach. Details of the program and preliminary outcome data are provided.

Evidence-Based Nursing Care Management for the Pregnant Woman With an Ostomy

Pregnancy presents many problems without working through additional problems in coping with an ostomy. Yet many women with an ostomy do get pregnant and do deliver healthy babies. Evidence-based nursing is of the utmost importance, as there is little published information on this topic. Because of the scarcity of pregnant subjects within the ostomy category, most studies, by necessity, select a purposive subject base. Therefore, other information sources regarding nursing management of the pregnant woman with an ostomy take on considerably more importance. This article explores other forms of evidence that can be used in managing the care of pregnant ostomy patients and specifically how nurses can integrate various sources of information in designing an evidence-based nursing care plan. Nonpharmacologic forms of relaxation therapy, easily used by nurses, such as mindfulness-based stress reduction, guided imagery, and hypnosis, are also identified as some ways nurses can relieve anxiety and experiential stress associated with pregnancy in women who have an ostomy.

Collaborative care management for a pregnant woman with an ostomy

Pregnant women with an ostomy face many challenges during the prenatal period. Although these challenges may be present, pregnancy in the ostomate is presented as a continuum of health and wellness in this article. Collaborative care professionals, especially nurses and midwives, are often the most accessible professional sources for health care information, but current research and information on this topic is sparse. Ostomy-related problems that may occur during pregnancy, include: intestinal obstruction, peristomal hernia, pouching problems, including the effect of nausea and vomiting on pouch hydration, stomal retraction, stenosis, or laceration, and stomal prolapse. Three types of ostomies are discussed: continent ileostomies, urostomies and colostomies. A description of the normal characteristic appearance of each is also included. Collaborative care from pre-conception through the post partum period is described with emphasis on teaching self-help techniques such as: special nutritional considerations, how to recognize potential problems, and how to fit and adapt appliances to the changing body form of the patient as the pregnancy progresses. Phenomenologic information about the pregnant ostomate's perceptions about her pregnancy experience is also presented. Psycho-prophylaxis methods of complementary therapy alternatives alleviating nausea and vomiting within pregnancy, as well as the pain of childbirth are also presented. Although nursing/midwifery management of a pregnant ostomy patient is a challenge, those challenges are surmountable and outcomes resemble those found in the general population.

Five cases of severe cardiac disease in pregnancy: outcomes and costs

The obstetric, medical and anaesthetic management of five pregnant patients with a variety of significant cardiac problems is briefly reviewed. The duration of hospitalisation, and the use of high dependency and intensive care are documented. Financial costs are estimated and their implications for the care of such patients during and following pregnancy are discussed.