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  • 1.
    Hildén, Karin
    Örebro University, School of Medical Sciences.
    Gestational diabetes, obesity and pregnancy outcomes in Sweden2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The overall aim of the thesis was to evaluate maternal and fetal outcomes in relation to gestational diabetes mellitus (GDM) in both a shortand long term perspective.

    Study I was a population based cohort study including 1 249 908 pregnancies during the years 1998-2012. Maternal outcomes and fetal size were studied in relation to BMI and presence/absence of GDM. The conclusions were that maternal overweight and obesity are associated with similar increments in risks of adverse maternal outcomes and delivery of large-for-gestational-age infants in women with and without gestational diabetes. Study II was a population based cohort study using the same cohort as in study I. Fetal outcomes were studied in relation to GDM-status and BMI. Interaction between GDM and BMI for the outcomes was also analyzed. Conclusions were that excess maternal weight and GDM were, both major independent risk factors for adverse, perinatal outcomes, there were no intercation. In study III the same cohort was used to study time trends 1998-2012 in maternal and perinatal outcomes in women with GDM. Trends were also analyzed in women without GDM for comparison. This study showed that there have been improvements in fetal outcomes for women with GDM. But since the improvements were similar or less than the changes in the background population this was probably not due to better medical care for women with GDM alone. The conlusion is that there is still a lot to do to improve outcomes for women with GDM. Study IV was a case control study aiming to evaluate if there was an interaction between GDM and preeclampsia (PE) or if the conditions were independent risk factors for later cardio vascular disease (CVD). We also wanted to analyze how BMI influenced the association between PE and later CVD. We showed that GDM and PE are independently associated with elevated risk for CVD. The association of PE and CVD is not affected by BMI to a great extent as is the case in GDM and CVD.

    List of papers
    1. Overweight and obesity: a remaining problem in women treated for severe gestational diabetes
    Open this publication in new window or tab >>Overweight and obesity: a remaining problem in women treated for severe gestational diabetes
    2016 (English)In: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491, Vol. 33, no 8, p. 1045-1051Article in journal (Refereed) Published
    Abstract [en]

    Aim: To analyse the impact of overweight and obesity on the risk of adverse maternal outcomes and fetal macrosomia in pregnancies of women treated for severe gestational diabetes.

    Methods This was a population-based cohort study including all singleton pregnancies in Sweden without pre-existing diabetes in the period 1998-2012. Only mothers with an early- pregnancy BMI of ≥18.5 kg/m² were included. Logistic regression analysis was used to determine odds ratios with 95% CIs for maternal outcomes and fetal growth. Analyses were stratified by maternal gestational diabetes/non-gestational diabetes to investigate the impact of overweight/obesity in each group.

    Results: Of 1 249 908 singleton births, 13 057 were diagnosed with gestational diabetes (1.0%). Overweight/obesity had the same impact on the risks of caesarean section and fetal macrosomia in pregnancies with and without gestational diabetes, but the impact of maternal BMI on the risk of preeclampsia was less pronounced in women with gestational diabetes. Normal-weight women with gestational diabetes had an increased risk of caesarean section [odds ratio 1.26 (95% CI 1.16-1.37)], preeclampsia [odds ratio 2.03 (95% CI 1.71-2.41)] and large-for-gestational-age infants [odds ratio 2.25 (95% CI 2.06-2.46)]. Risks were similar in the overweight group without gestational diabetes, caesarean section [odds ratio 1.34 (1.33-1.36)], preeclampsia odds ratio [1.76 (95% CI 1.72-1.81)], large-for-gestational-age [odds ratio 1.76 (95% CI 1.74-1.79)].

    Conclusions: Maternal overweight and obesity is associated with similar increments in risks of adverse maternal outcomes and delivery of large-for-gestational-age infants in women with and without gestational diabetes. Obese women with gestational diabetes are defined as a high-risk group. Normal-weight women with gestational diabetes have similar risks of adverse outcomes to overweight women without gestational diabetes.

    Place, publisher, year, edition, pages
    Hoboken, USA: Wiley-Blackwell Publishing Inc., 2016
    National Category
    Endocrinology and Diabetes
    Identifiers
    urn:nbn:se:oru:diva-50308 (URN)10.1111/dme.13156 (DOI)000379936000005 ()27172974 (PubMedID)2-s2.0-84978818273 (Scopus ID)
    Note

    Funding Agency:

    Research Committee of Örebro County Council

    Available from: 2016-05-27 Created: 2016-05-16 Last updated: 2018-11-19Bibliographically approved
    2. Are gestational diabetes and adiposity independent risk factors for perinatal outcomes?: A population based cohort study in Sweden
    Open this publication in new window or tab >>Are gestational diabetes and adiposity independent risk factors for perinatal outcomes?: A population based cohort study in Sweden
    Show others...
    2018 (English)In: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491Article in journal (Refereed) Accepted
    Place, publisher, year, edition, pages
    Hoboken, USA: Wiley-Blackwell Publishing Inc., 2018
    National Category
    Endocrinology and Diabetes
    Identifiers
    urn:nbn:se:oru:diva-69788 (URN)
    Available from: 2018-10-24 Created: 2018-10-24 Last updated: 2019-06-14Bibliographically approved
    3. Trends in pregnancy outcomes for women with gestational diabetes mellitus in Sweden 1998-2012: a nationwide cohort study
    Open this publication in new window or tab >>Trends in pregnancy outcomes for women with gestational diabetes mellitus in Sweden 1998-2012: a nationwide cohort study
    Show others...
    (English)Manuscript (preprint) (Other academic)
    National Category
    Endocrinology and Diabetes
    Identifiers
    urn:nbn:se:oru:diva-69789 (URN)
    Available from: 2018-10-24 Created: 2018-10-24 Last updated: 2018-10-24Bibliographically approved
    4. Cardiovascular disease among women with previous preeclampsia and/or gestational diabetes mellitus: a national case control study
    Open this publication in new window or tab >>Cardiovascular disease among women with previous preeclampsia and/or gestational diabetes mellitus: a national case control study
    Show others...
    (English)Manuscript (preprint) (Other academic)
    National Category
    Endocrinology and Diabetes
    Identifiers
    urn:nbn:se:oru:diva-69790 (URN)
    Available from: 2018-10-24 Created: 2018-10-24 Last updated: 2018-11-19Bibliographically approved
  • 2.
    Hildén, Karin
    et al.
    Örebro University, School of Medical Sciences.
    Arntyr-Hellgren, Paulina
    Magnuson, Anders
    Hanson, Ulf
    Simmons, David
    Örebro University, School of Medical Sciences.
    Fadl, Helena
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Born over 4500 g: the trends in birth trauma and mode of delivery in women with GDM and type 1 diabetes in Sweden between 1998-20122018Conference paper (Refereed)
    Abstract [en]

    Background: We have previously shown that during the years 1998-2012, the overall incidence of LGA and birthweight decreased in both women with and without GDM in Sweden, and unpublished preliminary results show that there is a converse trend among women with T1DM. The incidence of Erbs palsy also decreased in the GDM and background population, but remained unchanged for women with T1DM. Since macrosomia is one of the most prominent risk factors for Erb´s palsy and delivery complications, the aim of the study was to evaluate trends in incidence of Erb´s palsy and delivery mode in the macrosomic group defined as weight ≥4500g and we present here our preliminary results.

    Method: This is a cohort study in Sweden 1998-2012 , including singleton macrosomic (≥4500 g) births. Vaginal deliveries were selected for the analyses relating to Erb´s plasy. Poisson regression was used to evaluate trends per year in both the GDM, T1DM and the background population. Results were partly stratified on BMI, to be able to detect any group differences in trends. P-value of <0.05 was considered statistically significant.

    Results: In total there were 57 2015 macrosomic infants, of whom (n= 36 933, 64,6%) were delivered vaginally. Of these, only 2.1 % (n=798) were vaginally delivered by women with GDM, (1.4%) type 2 diabetes (0.1%) or T1DM (0.7%). The trend in Erb´s palsy decreased significantly in the background population at a rate of OR 0.954 (95% CI 0.936-0.973) per year. For women with GDM or T1DM there was no significant change in incidence of trends over these years for Erb´s palsy. As for Caesarean section (CS) there was a significant increase per year for GDM pregnancies (OR 1.028, 95% CI 1.007-1.049) and in the background population (1.018 95% CI 1.013-1.022). No change was seen for CS in pregnancies with T1DM.

    Conclusion: Even though the rates of LGA and birthweight have decreased in Sweden over this time period for women with GDM and the background population, we could not see a significant decrease in Erb´s palsy among women with vaginal births in either the GDM group or for women with T1DM in the macrosomic infants. However, a decrease was seen in the incidence of Erb´s palsy in the macrosomic babies in the background population. The rates of CS have significantly increased in the background population and for GDM pregnancies, but been stable for T1DM. We conclude that the disparity in risk of Erbs has grown over this time period. Further work is needed to ascertain whether this is due to the need for improved surveillance, a higher CS rate, and/or improved glycaemic management (or other factors).

  • 3.
    Hildén, Karin
    et al.
    Örebro University, School of Medical Sciences. Department of Obstetrics and Gynaecology.
    Hanson, Ulf
    Örebro University, School of Health Sciences. DeDepartment of Obstetrics and Gynaecology, School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
    Persson, M.
    Department of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden.
    Fadl, Helena
    Örebro University, School of Medical Sciences. Department of Obstetrics and Gynaecology.
    Overweight and obesity: a remaining problem in women treated for severe gestational diabetes2016In: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491, Vol. 33, no 8, p. 1045-1051Article in journal (Refereed)
    Abstract [en]

    Aim: To analyse the impact of overweight and obesity on the risk of adverse maternal outcomes and fetal macrosomia in pregnancies of women treated for severe gestational diabetes.

    Methods This was a population-based cohort study including all singleton pregnancies in Sweden without pre-existing diabetes in the period 1998-2012. Only mothers with an early- pregnancy BMI of ≥18.5 kg/m² were included. Logistic regression analysis was used to determine odds ratios with 95% CIs for maternal outcomes and fetal growth. Analyses were stratified by maternal gestational diabetes/non-gestational diabetes to investigate the impact of overweight/obesity in each group.

    Results: Of 1 249 908 singleton births, 13 057 were diagnosed with gestational diabetes (1.0%). Overweight/obesity had the same impact on the risks of caesarean section and fetal macrosomia in pregnancies with and without gestational diabetes, but the impact of maternal BMI on the risk of preeclampsia was less pronounced in women with gestational diabetes. Normal-weight women with gestational diabetes had an increased risk of caesarean section [odds ratio 1.26 (95% CI 1.16-1.37)], preeclampsia [odds ratio 2.03 (95% CI 1.71-2.41)] and large-for-gestational-age infants [odds ratio 2.25 (95% CI 2.06-2.46)]. Risks were similar in the overweight group without gestational diabetes, caesarean section [odds ratio 1.34 (1.33-1.36)], preeclampsia odds ratio [1.76 (95% CI 1.72-1.81)], large-for-gestational-age [odds ratio 1.76 (95% CI 1.74-1.79)].

    Conclusions: Maternal overweight and obesity is associated with similar increments in risks of adverse maternal outcomes and delivery of large-for-gestational-age infants in women with and without gestational diabetes. Obese women with gestational diabetes are defined as a high-risk group. Normal-weight women with gestational diabetes have similar risks of adverse outcomes to overweight women without gestational diabetes.

  • 4.
    Hildén, Karin
    et al.
    Örebro University, School of Medical Sciences. Department of Obstetrics & Gynaecology.
    Hanson, Ulf
    Department of Women’s and Children’s Health, Uppsala University, Sweden; School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Persson, M.
    Department of Medicine, Clinical Epidemiology Unit, Karolinska Universitetssjukhuset Solna, Karolinska Institutet, Sweden.
    Magnuson, A.
    Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, sweden.
    Simmons, David
    Örebro University, School of Medical Sciences. School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia.
    Fadl, Helena
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Obstetrics & Gynaecology.
    Are gestational diabetes and adiposity independent risk factors for perinatal outcomes?: A population based cohort study in Sweden2018In: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491Article in journal (Refereed)
  • 5.
    Hildén, Karin
    et al.
    Örebro University, School of Medical Sciences. Department of Obstetrics and Gynaecology.
    Magnuson, A.
    Clinical Epidemiology and Biostatistics, Örebro University Hosptial, Örebro, Sweden.
    Montgomery, Scott
    Örebro University, School of Medical Sciences. Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.
    Schwarcz, E.
    Department of Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Hanson, U.
    Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden; School of Medical Sciences, Örebro University, Örebro, Sweden .
    Simmons, David
    Örebro University, School of Medical Sciences. School of Medicine, Western Sydney University, Campbelltown New South Wales, Australia.
    Fadl, Helena
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Obstetrics and Gynaecology.
    Cardiovascular disease among women with previous preeclampsia and/or gestational diabetes mellitus: a national case control studyManuscript (preprint) (Other academic)
  • 6.
    Hildén, Karin
    et al.
    Örebro University, School of Medical Sciences. Department of Obstetrics and Gynaecology.
    Magnuson, Anders
    Clinical Epidemiology and Biostatistics, School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Hanson, Ulf
    Clinical Epidemiology and Biostatistics, School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
    Simmons, David
    Örebro University, School of Medical Sciences. School of Medicine, Western Sydney University, Campbelltown New South Wales, Australia.
    Fadl, Helena
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Obstetrics and Gynaecology.
    Trends in pregnancy outcomes for women with gestational diabetes mellitus in Sweden 1998-2012: a nationwide cohort studyManuscript (preprint) (Other academic)
  • 7.
    Stenberg, Erik
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery.
    Ruoqing, Chen
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Hildén, Karin
    Örebro University, School of Medical Sciences. Department of Obstetrics and Gynecology.
    Fall, Katja
    Örebro University, School of Medical Sciences. Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Pregnancy As a Risk Factor for Small Bowel Obstruction After Laparoscopic Gastric Bypass Surgery2018In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To evaluate whether pregnancy is associated with increased risk for small bowel obstruction after laparoscopic gastric bypass surgery.

    BACKGROUND: Small bowel obstruction is a common and feared long-term complication to laparoscopic gastric bypass surgery that may be more common during pregnancy. It is unclear if the risk truly increases during pregnancy.

    METHODS: Women, 18 to 55 years, operated with a primary laparoscopic gastric bypass procedure from 2010 until 2015 were identified through the Scandinavian Obesity Surgery Registry (n = 25,853). Through record-linkage to the Medical Birth Registry, the National Patient Registry, and review of hospital charts, information on pregnancy periods and outcome were obtained. The main outcome was operation due to small bowel obstruction after the laparoscopic gastric bypass procedure.

    RESULTS: Pregnancy was associated with increased risk for small bowel obstruction following laparoscopic gastric bypass surgery (incidence rates 46.5, 95% CI 38.0-56.9/1000 person-years, vs 20.9 95% CI 19.9-22.0; adjusted-HR 1.72, 95% CI 1.39-2.12, P < 0.001). While no excess risk was observed during the first trimester, the second (adjusted-HR 1.67, 95% CI 1.17-2.39, P = 0.005) and third (adjusted-HR 2.69, 95% CI 2.02-3.59, P < 0.001) conferred increased risk. The incidence rate of small bowel obstruction during pregnancy was 42.9 (95% CI 32.4-57.0/1000 person-years) among women for whom the mesenteric defects had been closed during the primary procedure, and 53.2 (95% CI 38.9-72.8/1000 person-years) for women in whom they had been left open.

    CONCLUSION: Pregnancy is associated with increased risk for small bowel obstruction after laparoscopic gastric bypass surgery during the second and third trimesters.

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