| 1. |
- Ternby, Ellen, 1987-
(författare)
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Information prior to prenatal diagnosis : Knowledge, informational needs and decision-making
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this thesis was to explore different aspects of information relevant to decision-making regarding prenatal diagnosis (PND) for chromosomal anomalies (CA). In Papers I–II, women and partners undergoing combined ultrasound and biochemistry (CUB) tests, invasive tests or declining PND for CAs answered a questionnaire. Overall, expectant parents had varying to low levels of knowledge about Down syndrome (DS), with few differences between women and partners, or between those accepting or declining PND. Thus, knowledge at these levels does not seem to influence the decision to accept or decline PND. Some seem to regard CUB as a routine test.Paper III explored midwives' perspectives with a questionnaire. The majority believed they had not received sufficient education about PND, and few felt knowledgeable enough to provide information about DS. Most midwives desired more education regarding tests and DS. Actual knowledge levels concerning DS varied, and in some cases, were low.Paper IV explored the factors influencing decisions concerning PND through interviews with pregnant women. The decision-making process is affected by individual factors (i.e. attitude towards anomalies, worry and need for reassurance, and self-perceived risk) and external factors (i.e. test characteristics and influence from others). The quality of life for an affected individual and the impact on the family is important for some women when making decisions about PND. Healthcare professionals can influence women’s decisions through their attitudes, how they present the tests, and the woman’s individual probability of CAs.Paper V used Q methodology to explore women’s views on what is important when receiving information about PND. Some women prefer receiving information gradually, while others prefer comprehensive information early in pregnancy. Some value information about the conditions tested for early in the process. The extent to which women wanted to involve their partner in the decision-making process varied. None preferred group information sessions.In conclusion, providing information and pre-test counselling to pregnant women is a complex task. There is room for improvement in the information provided to expectant parents, and in the education provided to midwives related to PND and DS. Women’s decisions regarding PND are influenced by both individual and external factors. Information about test characteristics and conditions tested for could be helpful for pregnant women when they make decisions. Healthcare professionals’ approach can influence women’s decisions. Women have varying informational needs, making individual and non-directive pre-test counselling with a competent healthcare professional essential to facilitate informed decision-making.
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| 2. |
- Hildebrand, Eric
(författare)
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Prenatal diagnosis of structural malformations and chromosome anomalies : Detection, influence of Body Mass Index and ways to improve screening
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Prenatal diagnosis of structural malformations and chromosome anomalies is possible in the presence of an effective screening with ultrasound during pregnancy. The continuous evolution of the ultrasound equipment facilitates the examination. However there are challenges in terms of the increasing prevalence of obesity among the pregnant women and the need of training of the personnel performing the scans. In the Southeast region of Sweden all pregnant women are offered screening with ultrasound during pregnancy. From 2009 almost all women in the region are offered two examinations, one in week 11-14 assessment of gestational age and combined screening for aneuploidy. Congenital heart disease (CHD) is the most common congenital defect. About one third of the CHD cases will have a duct-dependent anomaly that is potentially life-threatening if not detected before birth.Aims: To assess the sensitivity for detecting structural malformations and chromosome anomalies by a routine ultrasound either in gestational week 11-14 or 18-20. To estimate the influence of a high Body Mass Index (BMI) in detecting fetal structural anomalies by ultrasound. To evaluate the possibility for introducing a more accurate fetal cardiac ultrasound screening based on five different transverse views and color Doppler. To determine if the risk-estimate for trisomy 21 from the screening procedure varies over BMI strata and if obesity is associated with an increased risk of Down syndrome in the offspring.Material and methods: Outcome measures from 21189 consecutive ultrasound examinations in the first and second trimester were analyzed and compared. The fetal anomaly diagnoses were also grouped in four BMI-groups. Then, a two-day course in examining of the fetal heart was given, analyzed and followed up. To evaluate the effect of BMI on the combined screening, 10224 patients were divided in six BMI categories. Outcomes were evaluated over BMI strata. The possibility of an association between maternal obesity and Down syndrome was analyzed in a nationwide cohort of 1568604 women giving birth in Sweden.Results: At the first trimester scan 13% of all anomalies were detected vs 29% in the second trimester. For aneuploidy the corresponding results were 71% vs 42%, and for lethal anomalies 88% vs 92%. If divided into BMI-groups 26% of the malformations were detected in the group of normal weight women compared to 19% among the obese. For malformations with long-term handicap the corresponding figures were 46% vs 27%. After the course in examination of the fetal heart uncertainty was lower and the familiarity with the new technique was enhanced. The ability to perform the new method remained at follow up. In the combined screening, the observed and expected number with a risk of Downs syndrome >1/300 were similar in each BMI-group. Obese women had an increased risk of giving birth to an infant with Downs syndrome compared with normal weight women.Conclusions: There was an advantage to the scan in the second trimester discovering malformations overall and an advantage to the early scan concerning aneuploidy. Lethal malformations were detected at a high level in both groups. The detection rate seemed lower for the obese women. In the screening for Down syndrome, the risk-estimate is unaffected by BMI. Detection of heart malformations needs improvement. By implementing new image modalities and providing hands-on training uncertainty in examining the fetal heart can be reduced.
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| 3. |
- Belachew, Johanna, 1976-
(författare)
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Retained Placenta and Postpartum Haemorrhage
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim was to explore the possibility to diagnose retained placental tissue and other placental complications with 3D ultrasound and to investigate the impact of previous caesarean section on placentation in forthcoming pregnancies.3D ultrasound was used to measure the volumes of the uterine body and cavity in 50 women with uncomplicated deliveries throughout the postpartum period. These volumes were then used as reference, to diagnose retained placental tissue in 25 women with secondary postpartum haemorrhage. All but three of the 25 women had retained placental tissue confirmed at histopathology. The volume of the uterine cavity in women with retained placental tissue was larger than the reference in most cases, but even cavities with no retained placental tissue were enlarged (Studies I and II).Women with their first and second birth, recorded in the Swedish medical birth register, were studied in order to find an association between previous caesarean section and retained placenta. The risk of retained placenta with heavy bleeding (>1,000 mL) and normal bleeding (≤1,000 mL) was estimated for 19,459 women with first caesarean section delivery, using 239,150 women with first vaginal delivery as controls. There was an increased risk of retained placenta with heavy bleeding in women with previous caesarean section (adjusted OR 1.61; 95% CI 1.44-1.79). There was no increased risk of retained placenta with normal bleeding (Study III).Placental location, myometrial thickness and Vascularisation Index were recorded on 400 women previously delivered by caesarean section. The outcome was retained placenta and postpartum haemorrhage (≥1,000 mL). There was a trend towards increased risk of postpartum haemorrhage for women with anterior placentae. Women with placenta praevia had an increased risk of retained placenta and postpartum haemorrhage. Vascularisation Index and myometrial thickness did not associate (Study IV).In conclusion: 3D ultrasound can be used to measure the volume of the uterine body and cavity postpartum, but does not increase the diagnostic accuracy of retained placental tissue. Previous caesarean section increases the risk of retained placenta in subsequent pregnancy, and placenta praevia in women with previous caesarean section increases the risk for retained placenta and postpartum haemorrhage.
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| 4. |
- Bergman, Eva, 1959-
(författare)
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Symphysis Fundus Measurements for Detection of Intrauterine Growth Retardation
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- A case-control study was performed to evaluate the Swedish population-based symphysis fundus (SF) reference curves. The study included 242 small for gestational age (SGA) neonates (169 term and 73 preterm infants) as cases and 296 non-SGA infants as controls. Two Swedish SF curves were evaluated. In term pregnancies they showed a sensitivity of 32 % and 51 % and a specificity of 90 % and 83 %, respectively, at a cut-off level of < - 2 SD from the mean according to the SF reference curve. The sensitivity for SGA was higher in preterm pregnancies (49 % and 58 %, respectively) and the first alarm below – 2 SD was noted before 32 weeks in 37 % and 43 % of the preterm pregnancies, respectively. (Study I) A study of self-administered SF measurements was designed to achieve more regular and frequent SF measurements. Thirty-three women with singleton, ultrasound dated pregnancies performed SF measurements on average 14 weeks from gestational week 20 to 25 until delivery. Self-administered SF measurements were higher and had higher variance than midwives’ measurements. Four consecutive SF measurements on each occasion can compensate for higher variance. Reliable self-administered SF measurements can be obtained. (Study II) Self-administered SF measurements from 191 women were used to construct absolute and relative SF growth references. The influence of fetal sex, maternal obesity and parity was assessed in regression models. The lnSF growth was statistically influenced by maternal obesity, and a borderline significance was recorded for fetal sex and parity. Statistical analysis and graphical displays show no evidence that the relative lnSF growth should be dependent on these variables. (Study III) To improve detection of infants with intrauterine growth restriction (IUGR) rather than SGA a new statistical model (the SR method) was used. The SR method was evaluated with SF measurements from 1122 pregnant women. The sensitivity for neonatal morbidity and SGA was low, between 6 and 36 % for SGA (< -2SD). Neonates classified as SGA (< -2SD and < 10th percentile) had increased morbidity compared with the total study group. Neonates suspected to be SGA before delivery by the population-based SF measurement method had lower morbidity than those not suspected. The SR method was found not to improve detection of fetuses with increased morbidity or SGA neonates in this study. Better screening methods to detect IUGR and SGA prior to delivery are needed. (Study IV)
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| 5. |
- Palm, Maria, 1969-
(författare)
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Oxidative Stress, Angiogenesis and Inflammation in Normal Pregnancy and Postpartum
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aims were to investigate oxidative stress (I), angiogenesis (II) and inflammation (III-IV) in healthy women during pregnancy and postpartum. Oxidative stress was estimated by measurement of 8-iso-PGF2α and the antioxidants α- and γ-tocopherol. The angiogenic factors PlGF, VEGF-A and the antiangiogenic factor sFlt1 were measured to estimate angiogenesis. PTX3, IL-6, TNF-α and a PGF2α metabolite were measured to estimate inflammation.Out of 52 included women, 15 had minor pregnancy complications and 37 were classified as normal. In study III data from all 52 women were used. For the other studies (I, II and IV) only data from the 37 women with normal pregnancy were used. Pregnancy was associated with increased levels of 8-iso-PGF2α with advancing gestational age. The median postpartum value corresponded to values observed in early gestation and a significant decrease was observed from late pregnancy to postpartum. Lipid-adjusted α- and γ-tocopherol levels decreased with advancing gestational age (I). PlGF increased from early pregnancy until weeks 29–30 and thereafter decreased until week 40. sFlt1 levels were relatively constant until weeks 29–30, when they increased, reaching a peak at weeks 39–40. Postpartum levels were low. The sFlt1:PlGF ratio decreased from weeks 9–12, was constantly low from weeks 19–20 to 37–38 and then increased to weeks 39–40. VEGF-A was detectable in only 8 % of the samples during pregnancy and in 64 % postpartum (II). There was a continuous increase of PTX3 as pregnancy progressed. The increase was most evident after week 31 with the highest levels just before delivery (III). IL-6 increased throughout pregnancy and remained high postpartum. No change in TNF-α could be seen with advancing gestational age or postpartum. The PGF2α metabolite levels increased throughout pregnancy and decreased postpartum (IV).In conclusion, normal pregnancy is associated with mild oxidative stress and inflammation. This might have physiological effects for normal pregnancy development. By delineating how these mediators of oxidative stress, angiogenesis and inflammation fluctuate throughout normal pregnancy and postpartum, we have established a reference for studies of these factors in pregnancy complications.
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| 6. |
- Amini, Hashem
(författare)
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Fetal Anomalies : Surveillance and Diagnostic Accuracy of Ultrasound and Magnetic Resonance Imaging
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aims were to investigate the accuracy of ultrasound in diagnosis of structural fetal anomalies with special focus on false positive findings (I), to evaluate the additional value of second trimester fetal MRI on pregnancy management (II-III) and to estimate the ascertainment in the Swedish Birth Defects Registry and incidence of spina bifida and cleft lip/palate (IV). Retrospectively, 328 fetal autopsies were identified where pregnancies were terminated due to ultrasonographically diagnosed fetal anomalies. In 175 (53.4 %) cases ultrasound and fetal autopsy were identical, in 124 (37.8 %) ultrasound was almost correct, in 23 (7.0 %) ultrasound diagnoses could not be verified, but fetal autopsy showed other anomalies with at least the same prognostic value and in six (1.8 %) ultrasound diagnosis could not be verified and autopsy showed no or less severe anomalies (I). Prospectively, 29 pregnancies with CNS- (II) and 63 with non-CNS-anomalies (III) were included. In the CNS study MRI provided no additional information in 18 fetuses (62 %), additional information without changing the management in 8 (28 %) and additional information altering the pregnancy management in 3 (10%). In the non-CNS study the corresponding figures were 43 (68 %), 17 (27 %) and three (5 %), respectively. MRI in the second trimester might be a clinically valuable adjunct to ultrasound for the evaluation of CNS anomalies, especially when the ultrasound is inconclusive due to maternal obesity (II) and in non-CNS anomalies in cases of diaphragmatic hernia or oligohydramnios (III). In newborns, the ascertainments of birth defects are relatively high and assessable, but in pregnancy terminations they are lower or unknown. The incidence of newborns with spina bifida has decreased because of an increased rate of pregnancy terminations (>60%). There is room for improvement concerning the reporting of anomalies from terminated pregnancies (IV).
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| 7. |
- Axelsson, Rose-Marie, 1962-
(författare)
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Formbara människor : Högre utbildning och arbete som utsnitt ur läkares och civilingenjörers levnadsbanor
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Fokus i denna avhandling utgör läkares och civilingenjörers kunskaps- och identifikationsprocesser under utbildning och arbete – vilka studeras som utsnitt ur levnadsbanor. Syftet är att beskriva och tolka relationen mellan högre utbildning och arbete, dels utifrån föreställningar i forskning och policy, dels utifrån människors subjektivitet, vardagserfarenheter och liv. Studien baseras på textanalys och intervjuer med läkare och IT-ingenjörer under de första åren i arbetslivet och yrket. Kännetecknande är att processer följs över tid genom en longitudinell design.Den teoretiska ramen struktureras runt tre länkade teman: Kunskap och dynamiker i det samtida samhället; Högre utbildning och arbete; Människors formbarhet. Reflexiv tolkning utgör metodologisk ansats. Begreppen flexibilitet, stabilitet och ambivalens används dialektiskt vid analys av empiriska data.Avhandlingen visar att människors subjektivitet och vardagserfarenheter samspelar med generella föreställningar och sammanhangens reella förhållanden. Utbildnings- och yrkesval kan förstås som uttryck för såväl reflexiva livsprojekt som subjektiva dynamiker. Att formas till civilingenjör och läkare ter sig på vitt skilda sätt. Ingenjörerna formas till generalister och ”spelar med säkra kort” medan läkarna bygger en karaktär och ”spelar med sig själva som insats”. I arbetet använder civilingenjörerna titeln som en flexibel strategi – identifikation är främst bunden till plats, funktion och arbetstid. Läkarnas identifikation med yrket utgör ett konstant tillstånd – läkare är något de alltid är, också på fritiden – yrket är starkt bundet till person. Resultaten indikerar att både ingenjörs- och läkaryrket kännetecknas av livslånga kvalificeringsprocesser. De visar sig stark exkluderande över tid.Relationen mellan högre utbildning och arbetet diskuteras vidare i avhandlingen genom människors levnadsbanor och i termer av såväl formbara som hållbara liv.
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| 8. |
- Blixt, Ingrid, 1968-
(författare)
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Support to breastfeeding women
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Breastfeeding has important health benefits for mothers and infants in high- and low-income countries. For that reason, the World Health Organization (WHO) recommends exclusive breastfeeding for six months and partial breastfeeding for two years or longer. During pregnancy, a majority of women state that they intend to breastfeed, but they often stop earlier than they want because they face many barriers. Thus, it is important that women get the opportunity to breastfeed as long as they want. The overall aim of this thesis was to explore women’s perceptions of what assisted them in breastfeeding and their advice to healthcare professionals regarding breastfeeding support. An additional aim was to evaluate a breastfeeding support programme based on the Ten Steps to Successful Breastfeeding and the WHO’s recommendations on breastfeeding. In Paper I, an exploratory qualitative design was used based on the critical incident technique. The main finding was that supporting women to continue breastfeeding is both complex and multifaceted. In Paper II, an exploratory qualitative design illuminated that Swedish women advised healthcare professionals to provide up-to-date and evidence-based breastfeeding support in a sensitive and individualised manner to help the mothers to reach their breastfeeding goals. In Paper III, a breastfeeding training programme was evaluated using a pre-post design. The programme improved midwives’ and child healthcare nurses’ self-efficacy to provide evidence-based support in line with the Ten Steps to Successful Breastfeeding and the WHO’s recommendations on breastfeeding. Paper IV used an exploratory, longitudinal and qualitative design. Specifically, the study showed that partners who participated in the breastfeeding support programme and received structured support felt that both parents were important. They felt involved and that the family cooperated in the breastfeeding process. In conclusion, it is crucial to understand families’ perceptions and experiences of breastfeeding when supporting women to breastfeed. Midwives and child healthcare nurses have important roles to play by providing structured breastfeeding support during the breastfeeding process. The whole family must be targeted to decrease the partner’s feelings of being excluded. Both parents must be involved in a reflective dialogue, where healthcare professionals explain how breastfeeding works and how the partner can be involved without bottle-feeding the infant.
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| 9. |
- Cederlund, Frida, et al.
(författare)
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Magnetic resonance imaging in the second trimester as a complement to ultrasound for diagnosis of fetal anomalies
- 2024
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Ingår i: Acta Radiologica Open. - : Sage Publications. - 2058-4601. ; 13:5
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundFetal ultrasound has limitations, especially if the patient is obese or in cases with oligohydramnios. Magnetic resonance imaging (MRI) can then be used as a complement, but only few studies have focused on examinations in the second trimester.PurposeTo validate MRI as a complement to diagnose fetal anomalies in the second trimester.Material and MethodsThis retrospective study retrieved data from January 2008 to July 2012 from the Fetal Medicine Unit and Department of Radiology at Uppsala University Hospital. Ultrasound and MRI findings were reviewed in 121 fetuses in relation to the final diagnosis, including postpartum follow-up and autopsy results.ResultsOf the 121 fetuses, 51 (42%) had a CNS anomaly and 70 (58%) a non-CNS anomaly diagnosed or suspected. MRI provided additional information in 21% of all cases without changing the management and revealed information that changed the management of the pregnancy in 13%. When a CNS anomaly was detected or suspected, the MRI provided additional information in 22% and changed the management in 10%. The corresponding figures for non-CNS cases were 21% and 16%, respectively. The proportion of cases with additional information that changed the management was especially high in patients with a BMI >30 kg/m2 (25%) and in patients with oligohydramnios (38%). In five cases in category III, false-positive ultrasound findings were identified.ConclusionsMRI in the second trimester complements ultrasound and improves diagnosis of fetal CNS- and non-CNS anomalies especially when oligohydramnios or maternal obesity is present.
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| 10. |
- Glimskär Stålberg, Karin, 1971-
(författare)
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Prenatal Ultrasound and X-ray - Potentially Adverse Effects on the CNS
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim with this thesis was to assess the impact of prenatal ultrasound exposure on psychotic illness, childhood brain tumors (CBT) and school achievement, and to evaluate prenatal X-ray exposure and the risk of CBT.In a cohort study, children born in Malmö 1973-1978, where prenatal ultrasound was used routinely, were considered exposed (n=13, 212) and children born at hospitals with no use of ultrasound, were considered unexposed (n=357,733). Exposed men had a tendency toward a higher risk of schizophrenia. For other psychoses there were no differences between groups. Other factors related to place of birth might have influenced the results. In a case control study, children born 1975-1984 with a diagnosis of CBT (n=512), and randomly selected control children (n=524) were included. Exposure data on X-ray and ultrasound from antenatal records was completed with information from the Medical Birth Register. We found no overall increased risk for CBT after prenatal X-ray exposure. When stratifying by histological subgroups, primitive neuroectodermal tumors had the highest risk estimates. For ultrasound exposure, no increased risk for CBT was seen and numbers of examinations or gestational age at exposure had no substantial impact on the results. In a follow-up of a randomized trial on prenatal ultrasound scanning 1985-87, we assessed the children’s school grades when graduating from primary school (15-16 years of age). We performed analyses according to randomization, ultrasound exposure in the second trimester and exposure at any time during pregnancy. There were no differences in school performance for boys or girls according to randomization or exposure in the second trimester. Boys exposed to ultrasound any time during fetal life had a reduced mean score in physical education and small, non-significant increased risk of poor school performance in general.
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| 11. |
- Mulic-Lutvica, Ajlana, 1957-
(författare)
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Postpartum Ultrasound
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This study was undertaken to investigate the involutional changes of the uterus and uterine cavity by ultrasound (US), gray-scale and Doppler, after normal delivery, and to compare with the corresponding findings from women with puerperal complications, particularly retained placental tissue (RPT). The overall design was exploratory and prospective, with the use of descriptive statistics for analysis. Forty-two women with uncomplicated vaginal term delivery were examined on post-partum days 1, 3, 7, 14, 28 and 56. The AP diameters of the uterus and uterine cavity and morphological findings were recorded. The maximum AP diameters of the uterus and uterine cavity diminished from 92.0 mm on day 1 to 38.9 mm at day 56 and from 15.8 mm at day 1 to 4.0 mm at day 56, respectively. The uterus was most often empty in the early and late puerperium while a mixed echo pattern over the whole cavity was found during mid puerperium (I).Seventy-nine women with secondary post partum hemorrhage (SPH) were examined on the day they presented with clinical symptoms. US revealed an echogenic mass in the uterine cavity in 17 of 18 patients treated surgically and histology confirmed placental tissue in 14 of these. Sixty-one patients with either an empty cavity or mixed echo pattern had an uneventful puerperal course after conservative treatment (II).AP diameters and morphological findings for 55 women with endometritis, 28 after caesarean section and 20 after manual evacuation of the placenta overlapped extensively with normal references (III).The physiological vascular involution studied in 45 women after normal delivery showed that PI and RI indices did not change significantly until day 28 postpartum. The presence of at least one uterine artery notch was found in 13.3% of the women at day 1 and in 90.6% at day 56 postpartum (IV).PI and RI values were measured and compared with reference values in 20 women with clinical suspicion of RPT who were to undergo surgical evacuation. Mean resistance indices were below the 10th percentile for eight of these 20 women, but overlapping was considerable. Doppler US has limited value as a diagnostic tool for RPT. The absence of a hyper-vascular area in the myometrium does not exclude RPT but an echogenic mass in the cavity is a sign of RPT (V).
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