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- Adolfsson, Annsofie, 1960-, et al.
(författare)
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Miscarriage : women’s experience and its cumulative incidence
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Many women experience miscarriage every year. Every fourth woman who has given birth reports that she has previous experience of miscarriage. In a study of all women in the Swedish Medical Birth Register 1983-2003, we found that the number of cases of self reported miscarriage had increased in Sweden during this 21 year period. This increase can be explained by the introduction of sensitive pregnancy tests around 1990, as well as an increase in the mean age of the mothers, by approximately 3 years, during the observation period. The risk of miscarriage is 13% with the first child. With subsequent pregnancies, the risk of miscarriage is 8%, 6% and 4% with the second, third and fourth child, respectively.Thirteen of these women who had suffered a recent miscarriage were interviewed four months later, and their feelings of guilt and emptiness were explored. Their experience was that they wanted their questions to be answered, and that they wanted others to treat them as the mothers to be that they felt themselves to be. They also experienced the need for time to grieve their loss.Measurement of grief by means of the Perinatal Grief Scale (PGS) is used in research but has also been proposed for clinical use. We have translated this psychological instrument to Swedish, back-translated and tested it in a small pilot study. In a randomized controlled study, women with early miscarriage were allocated, either to a structured visit (study group) or a regular visit (control group) to a midwife. The structured visit was conducted according to the Swanson caring theory. We could conclude that the structured visit had no significant effect on grief compared to the regular visit, as measured using the PGS. However, women with the sub-diagnosis missed abortion have significantly more grief four months after early miscarriage, regardless of visit type.We also performed a content analysis of the tape-recorded structured follow-up visit. The code-key used was Bonanno and Kaltman’s general grief categorization. Women’s expression of grief after miscarriage was found to be very similar to the grief experienced following the death of a relative. Furthermore, the grief was found to be independent of number of children, women’s age, or earlier experience of miscarriage.Conclusions: Every fourth woman who gives birth reports that she has also experienced early miscarriage. The experience of these women is that they have suffered a substantial loss and their reaction is grief similar to that experienced following the death of a relative.
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| 2. |
- Eriksson, Katarina
(författare)
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Bacterial Vaginosis : Diagnosis, Prevalence, and Treatment
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Bacterial Vaginosis (BV) is a disorder of unknown etiology, characterized by a foul smelling vaginal discharge, loss or reduction of the normal vaginal Lactobacilli, and overgrowth of other anaerobic bacteria. Thus, it presents a formidable problem for clinicians as well as microbiologists researching its etiology, clinical course, treatment, and epidemiology. The present work focuses on the unresolved issues of the epidemiology and treatment of BV in order to provide valid methods for treatment studies of this condition and to describe the prevalence of BV in defined populations.The first study validates the use of PAP-stained smears in the diagnosis of BV. The study assesses the methods of Amsel’s clinical criteria and Nugent criteria on Gram-stain smears, against Pap-stained smears and also validates different observers. The result shows that the PAP-staining of vaginal smears is a good method in BV diagnosis; the kappa value is 0.86 (interobserver weighted kappa index) compared to 0.81 for Gram-stained smears, and 0.70 for rehydrated air-dried smears using the mean Nugent score as the criterion standard. This enables population based studies on archived PAP-stained smears from the screening of cervical cancer.In the second study, we use the knowledge gained from study one to investigate the prevalence of BV in a cohort from the population of Åland. The prevalences of BV on the Åland Islands were: 15.6 %, 11.9 %, 8.7 %, and 8.6% in 1993, 1998, 2003, and 2008, respectively. This means that the prevalence of BV decreased between1993-2008 from 15.6% to 8.6%. The confidence intervals are not overlapping, thus indicating a significant decrease in prevalence from 1993 to 2008.The third study is a prospective, double-blind placebo controlled treatment study of BV. After conventional treatment with clindamycin, the patients were treated with adjuvant treatment of Lactobacilli-loaded tampons or placebo. The study showed no differences between the treatment and the placebo group, indicating that the tampon does not work at all. There are a variety of possible explanations for the result, which are analyzed in this thesis.The fourth study aimed to evaluate whether clindamycin is retained for a long time in the vaginal mucosa, thus disturbing the Lactobacilli in an attempt to reimplant Lactobacilli in the probiotic treatment studies. In conventional treatment, it is also useful to know whether clindamycin is retained, especially when considering the pressure from antibiotics on the antimicrobial sensitivity pattern. In the study, we found that the clindamycin disappears rapidly.Conclusion: BV research requires effort from many different scientific disciplines and the riddle of this condition and its treatment can only be resolved by concerted actions in research and treatment. The vision for the future includes, among other factors, better molecular biology based diagnostic tools, and knowledge of population based bacterial floras.
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| 3. |
- Jakobsson, Tell, 1951-
(författare)
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Lactobacillus iners and the normal vaginal flora
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The ecological niche of the vagina contains a large number of different microbes that are constantly interacting with each other and the host. Culture methods have not been sufficient in order to resolve the complexity of the normal vaginal flora. Further, the methods for delineating normal flora from not normal flora are not easily handled and are traditionally not based on culture but on microscopy of elements of the vaginal fluid. In the work presented in this thesis, an international collaboration was established that pin-pointed some of the difficulties in classifying vaginal floras, including staining, sampling, and discordance when lactobacilli are few in number, and that emphasized the importance of the size of the vision field in microscopes. As lactobacilli are prominent members of the normal vaginal flora they need to be carefully classified if further work towards more robust scoring tools is to be achieved.Phenotypic methods have not been able to separate the closely related Lactobacillus species of the vagina. Progress in molecular biology has provided possibilities to characterize these lactobacilli, which are mainly from the Lactobacillus acidophilus group. In this work a large number of strains collected by true random sampling were subjected to RAPD-PCR, TTGE and multiplex PCR for species identification. The major species found were L. crispatus, L. gasseri and L. jensenii and the recently described L. iners. The presence of L. iners has not been detected in previous studies due to its special nutrient requirements. Development of pyrosequencing technology also made it possible to match signatures of the two variable regions V1 and V3 of the 16S rRNA gene of the vaginal lactobacilli and identify them to the species level in a high throughput manner. The study confirmed that the dominating flora in women with normal vaginal flora comprises the four species mentioned previously. Repetitive sampling during IVF-treatment with highly varying oestrogen levels demonstrates changes that possibly occur during changes in the natural life cycle. Furthermore, L. iners was found to be the first species to be established after spontaneously resolved or treated Bacterial Vaginosis.These findings can be of help in developing new strategies for regaining and retaining the normal vaginal flora.
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| 4. |
- Larsson, Per-Göran
(författare)
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Bacterial vaginosis : Diagnosis, treatment and significance in gynaecological practice
- 1991
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Bacterial vaginosis (BV) is a syndrome which is characterized of a disagreeable vaginal discharge but not necessarily an increase in discharge and is present in nearly 20-30% of women attending gynaecological out-patient clinics. Some women have BV unknowingly but others suffer the disagreeable discharge as a lifelong nuisance and areconstantly visiting physicians without relief. This problem has even been regarded as an aesthetic problem and has received little attention, especially from gynaecologists. The diagnosis of BV is based on the fulfilment of three out of four clinical criteria as introduced by Amsel in 1983. Few studies have been carried out investigating whether BV is a risk factor for other gynaecological diseases such as bleeding disturbances or postoperative infections. The aim of this thesis was to investigate the role of BV in gyrtaecological diseases and to evaluate whether it is possible to make a reliable diagnosis of BV using saved smears, such as air-dried or Papanicolaou (PAP)-stained smears. This would make it possible to investigate a large material and enable retrospective investigations. Since vaginal leucocytosis has been regarded as a sign of genital infection, women with BY and leucocytosis have often been withdrawn from clinical studies. The presence of leucocytosis among women without BV was therefore also investigated to evaluate if this practice is justifiable. The diagnosis of BV using Amsel's criteria was compared with the detection of clue cells in air-dried vaginal smears or with the detection of clue cells in PAP-stained smears. Detection of clue cells in air-dried smears had a sensitivity of 96% and a specificity of 98% in diagnosing BY, and detection of clue cells in PAP-stained smears had a sensitivity of 90% and a specificity of 95%. Leucocytosis cannot be used to exelude BV as nearly 30 OJo of all women have leucocytosis regardless of whether BV is present or not and that healthy women can normally have transient leucocytosis during a menstrual cycle. The significance of BV in postoperative infections after gynaecological surgery and bleeding disorders was studied. BV was found to be a risk factor for pelvic inflammatory disease after first-trimester abortion, and postoperative infection following abdominal hysterectomy. A common complaint with a multifactorial etiology at a gynaecological out-patient department is bleeding disorder. Women with BV and with Mobiluncus were treated in a double-blind study with either metronidazole or with placebo. BV was successfully treated in 76% of the women. The bleeding disorder was regularized in all successfully treated women. Women with BV are at risk of developing a post-operative infection after first trimester abortion. One-hundred and seventy-four women with BV were treated in a doubleblind study with either metronidazole or placebo the week before the abortion. There were 12.2% post-operative infections in the placebo group compared to 3.6% in the group treated with metronidazole. The treatment thus reduced the incidence of infection by more than 3 times. Using simple clinical criteria it is possible to identify a risk group which if treated will reduce the incidence of postoperative infections after legal abortion. In Sweden with 36 000 abortions each year preoperative treatment of 10 000 women with BV will prevent 860 post-abortion PID's per year.
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