<p>Amniocentesis (AC) and chorionic villus sampling (CVS) are the principal methods for fetal karyotyping. The aim of this thesis was to evaluate psychological reactions and risks associated with the procedures.</p><p>A semi-randomised study was made on 321 women, where AC (147) and CVS (174) at 10-13 weeks’ gestation were done trans-abdominally. Spontaneous fetal loss occurred in 6.8% and 1.7% of the women in the AC and CVS groups, respectively. Repeat testing was required more often in the AC (19.0%) than in the CVS (5.2%) group.</p><p>A subgroup of 94 women answered a questionnaire prior to the procedure. Anxiety was stated as reason for invasive testing in 38% of the women. Mean scores according to the Hospital Anxiety and Depression Scale for anxiety and depression were low. Likewise, mean scores for the Impact of Event Scale, evaluating the psychological distress evoked by the procedure, were low. Yet, a number of women had higher scores, indicating a risk of clinical anxiety and depression or psychological distress. The women worried most about miscarriage, fetal injury by the procedure and waiting for the result.</p><p>Fetal, infant and maternal outcomes were evaluated in a cohort of 71 586 women aged 35 to 49 years old, with single births in Sweden during 1991 to 1996. Altogether, 21 748 were exposed to AC and 1984 to CVS. Women exposed to AC and CVS were compared with non-exposed. Outcomes were extracted from the Swedish Medical Birth Register, the Swedish Hospital Discharge Register, and the Swedish Malformation Register. An increased risk of musculo-skeletal deformities, such as club foot (OR=1.45) and hip dislocation (OR=1.22), and respiratory disturbances such as neonatal pneumonia (OR=1.29), was found for infants born in the AC group. Risk increased with earlier gestation at the procedure. Fewer women in the AC group had a normal delivery and more had a Caesarean section. Complications related to the amniotic cavity and membranes (OR=1.15), hypotonic uterine dysfunction (OR=1.12) and instrumental vaginal deliveries (OR=1.11) were more common in the AC group. No significant differences were found for the CVS group.</p><p>CVS is the method of choice for prenatal karyotyping in the first trimester. AC should not be performed before 15 weeks’ gestation. Further research to develop methods to better identify women at increased risk of chromosomal abnormal pregnancies and to develop non-invasive tests for prenatal diagnosis is needed. Thereby, the number of women exposed to invasive procedures and the adverse effects caused by these procedures can be minimised.</p>

<p>The overall aims of the study were to determine the prevalence of anaemia in women of reproductive age and to investigate the underlying causes, as well as assess the effectiveness of antenatal care (ANC) interventions for anaemia prevention. Consecutive pregnant women booking for ANC (n=2235) were screened for anaemia, followed up and screened again late in pregnancy. Basic ANC interventions included iron and folate supplementation, malaria chemoprophylaxis and referral of severe anaemia cases, and in addition staff training and education for the women and the community at the study clinic. Non-pregnant women (n=504), adolescents: pregnant (n=76), non-pregnant (n=130), and boys (n=101) were also screened for anaemia. Haematological and biochemical investigations were made on anaemic cases.</p><p>The prevalences of anaemia and severe anaemia in pregnant women were 60% and 3.8%, respectively. The adolescent pregnant women were more anaemic, with an overall prevalence of anaemia of 76%. In the non-pregnant women the prevalence was 49%. Anaemia was more prevalent in adolescent girls than in boys, and iron deficiency was the main underlying cause in all groups. In the anaemic pregnant women, malaria and other infections were more common, and Serum ferritin therefore underestimates iron deficiency.</p><p>ANC interventions achieved a significant reduction in the prevalence of severe and moderate anaemia but only a moderate reduction in overall prevalence of anaemia. Time for treatment of anaemia during pregnancy is inadequate to correct pre-existing nutritional deficiencies, and all the underlying factors are not addressed. Anaemia control must include all women of reproductive age, starting with adolescents to build up their iron stores before pregnancy. ANC supplementation should include other nutrients, and there is also a need to identify and treat infections during pregnancy. Training of ANC providers and supervision as well as improvement in the logistics and supply supplements to the clinics needs reinforcement.</p>

<p>This thesis assesses some indicators of quality for maternity care in Tanzania, using antenatal management of anaemia and hypertension and emergency obstetric care as focal points. The care of pregnant women consecutively enrolled in antenatal care (n=379) was observed and compared with quality standard criteria. From a tertiary level labour ward 741 cases of eclampsia were identified and their antenatal care analyzed. A health systems analysis was performed for 205 cases of pregnancy complications at district level.</p><p>There was inadequate equipment and drugs, inadequate staff knowledge and motivation, and incorrect measurements for investigating anaemia and hypertension in pregnancy. Hospital incidence of eclampsia at tertiary level was 200/10,000 live births, and was not modified by antenatal care. The quality observed in the antenatal programme indicated little impact on either anaemia or hypertensive complications. Compliance with obstetric referral was only 46% and all four observed maternal deaths occurred due to transport problems. The proposed process indicators for essential obstetric care were inadequate to assess the quality of care on a district level. </p><p>There is a need to address structural weaknesses, to motivate health workers and to improve training on quality improvement. More research is warranted on indicators for obstetric needs, accessibility and referral system.</p>

Amniocentesis (AC) and chorionic villus sampling (CVS) are the principal methods for fetal karyotyping. The aim of this thesis was to evaluate psychological reactions and risks associated with the procedures. A semi-randomised study was made on 321 women, where AC (147) and CVS (174) at 10-13 weeks’ gestation were done trans-abdominally. Spontaneous fetal loss occurred in 6.8% and 1.7% of the women in the AC and CVS groups, respectively. Repeat testing was required more often in the AC (19.0%) than in the CVS (5.2%) group. A subgroup of 94 women answered a questionnaire prior to the procedure. Anxiety was stated as reason for invasive testing in 38% of the women. Mean scores according to the Hospital Anxiety and Depression Scale for anxiety and depression were low. Likewise, mean scores for the Impact of Event Scale, evaluating the psychological distress evoked by the procedure, were low. Yet, a number of women had higher scores, indicating a risk of clinical anxiety and depression or psychological distress. The women worried most about miscarriage, fetal injury by the procedure and waiting for the result. Fetal, infant and maternal outcomes were evaluated in a cohort of 71 586 women aged 35 to 49 years old, with single births in Sweden during 1991 to 1996. Altogether, 21 748 were exposed to AC and 1984 to CVS. Women exposed to AC and CVS were compared with non-exposed. Outcomes were extracted from the Swedish Medical Birth Register, the Swedish Hospital Discharge Register, and the Swedish Malformation Register. An increased risk of musculo-skeletal deformities, such as club foot (OR=1.45) and hip dislocation (OR=1.22), and respiratory disturbances such as neonatal pneumonia (OR=1.29), was found for infants born in the AC group. Risk increased with earlier gestation at the procedure. Fewer women in the AC group had a normal delivery and more had a Caesarean section. Complications related to the amniotic cavity and membranes (OR=1.15), hypotonic uterine dysfunction (OR=1.12) and instrumental vaginal deliveries (OR=1.11) were more common in the AC group. No significant differences were found for the CVS group. CVS is the method of choice for prenatal karyotyping in the first trimester. AC should not be performed before 15 weeks’ gestation. Further research to develop methods to better identify women at increased risk of chromosomal abnormal pregnancies and to develop non-invasive tests for prenatal diagnosis is needed. Thereby, the number of women exposed to invasive procedures and the adverse effects caused by these procedures can be minimised.

The overall aims of the study were to determine the prevalence of anaemia in women of reproductive age and to investigate the underlying causes, as well as assess the effectiveness of antenatal care (ANC) interventions for anaemia prevention. Consecutive pregnant women booking for ANC (n=2235) were screened for anaemia, followed up and screened again late in pregnancy. Basic ANC interventions included iron and folate supplementation, malaria chemoprophylaxis and referral of severe anaemia cases, and in addition staff training and education for the women and the community at the study clinic. Non-pregnant women (n=504), adolescents: pregnant (n=76), non-pregnant (n=130), and boys (n=101) were also screened for anaemia. Haematological and biochemical investigations were made on anaemic cases. The prevalences of anaemia and severe anaemia in pregnant women were 60% and 3.8%, respectively. The adolescent pregnant women were more anaemic, with an overall prevalence of anaemia of 76%. In the non-pregnant women the prevalence was 49%. Anaemia was more prevalent in adolescent girls than in boys, and iron deficiency was the main underlying cause in all groups. In the anaemic pregnant women, malaria and other infections were more common, and Serum ferritin therefore underestimates iron deficiency. ANC interventions achieved a significant reduction in the prevalence of severe and moderate anaemia but only a moderate reduction in overall prevalence of anaemia. Time for treatment of anaemia during pregnancy is inadequate to correct pre-existing nutritional deficiencies, and all the underlying factors are not addressed. Anaemia control must include all women of reproductive age, starting with adolescents to build up their iron stores before pregnancy. ANC supplementation should include other nutrients, and there is also a need to identify and treat infections during pregnancy. Training of ANC providers and supervision as well as improvement in the logistics and supply supplements to the clinics needs reinforcement.

This thesis assesses some indicators of quality for maternity care in Tanzania, using antenatal management of anaemia and hypertension and emergency obstetric care as focal points. The care of pregnant women consecutively enrolled in antenatal care (n=379) was observed and compared with quality standard criteria. From a tertiary level labour ward 741 cases of eclampsia were identified and their antenatal care analyzed. A health systems analysis was performed for 205 cases of pregnancy complications at district level. There was inadequate equipment and drugs, inadequate staff knowledge and motivation, and incorrect measurements for investigating anaemia and hypertension in pregnancy. Hospital incidence of eclampsia at tertiary level was 200/10,000 live births, and was not modified by antenatal care. The quality observed in the antenatal programme indicated little impact on either anaemia or hypertensive complications. Compliance with obstetric referral was only 46% and all four observed maternal deaths occurred due to transport problems. The proposed process indicators for essential obstetric care were inadequate to assess the quality of care on a district level. There is a need to address structural weaknesses, to motivate health workers and to improve training on quality improvement. More research is warranted on indicators for obstetric needs, accessibility and referral system.

<p><strong>Bakgrund:</strong> Blodtrycksavvikelse orsakad av graviditet är en viktig orsak till maternell och perinatal mortalitet och morbiditet. Blodtrycksavvikelse kan skapa oro, osäkerhet och ökad vårdberoende hos den gravida. Tillståndet kräver oftast behov av specialistmödravård. Kvinnan kan behöva sjukskrivas och läggas in på sjukhus för behandling och för tätare blodtryckskontroller. Ofta sker en dramatisk förändring av kvinnans livskvalitet och ökade kostnader för sjukvården.</p><p>Syftet med studien har varit att undersöka förekomsten av hemblodtrycksmätning i svensk mödrahälsovård samt studera barnmorskors uppfattning om hemblodtrycksmätning.</p><p><strong>Metod: </strong>Studien har baserats på strukturerade intervjuer med barnmorskor vid 50 specialist-mödravårdsmottagningar i Sverige. I uppsatsen studerade och diskuterade möjligheten att erbjuda utvalda patienter hemblodtrycksmätning som en egenvårdsåtgärd och som ett alternativ till de besök hos barnmorskan som endast relateras till blodtrycksmätning.</p><p><strong>Resultatet:</strong> Hemblodtrycksmätning förekommer i begränsad omfattning i svensk mödrahälsovård. Av 50 undersökta specialistmödravårdsmottagningar i landet, använde endast 8 hemblodtrycksmätning. I de mottagningarnas vårdrutiner ges patienten möjlighet att välja hemblodtrycksmätning och att låna utrustningen gratis. Patienterna förefaller nöjda med och positiva till hemblodtrycksmätningen. Trots att några barnmorskor var skeptiska till metoden uttryckte majoriteten en positiv inställning till hemblodtrycksmätning.</p><p><strong>Slutsatsen:</strong> Hemblodtrycksmätning skulle kunna användas som en egenvårdsåtgärd och som ett sätt att öka förståelsen för det individuella blodtrycksmönstret. Den skulle samtidigt kunna bidra till att minska osäkerhet, beroendeställning och maktlöshet den som en del patienter känner i samband med blodtrycksavvikelser. Förhoppningsvis kan den också bidra till en tidig upptäckt av avvikande blodtryck hos kvinnan, vilket kan leda till ett snabbare och mindre dramatiskt omhändertagande.</p>

Bakgrund: Blodtrycksavvikelse orsakad av graviditet är en viktig orsak till maternell och perinatal mortalitet och morbiditet. Blodtrycksavvikelse kan skapa oro, osäkerhet och ökad vårdberoende hos den gravida. Tillståndet kräver oftast behov av specialistmödravård. Kvinnan kan behöva sjukskrivas och läggas in på sjukhus för behandling och för tätare blodtryckskontroller. Ofta sker en dramatisk förändring av kvinnans livskvalitet och ökade kostnader för sjukvården. Syftet med studien har varit att undersöka förekomsten av hemblodtrycksmätning i svensk mödrahälsovård samt studera barnmorskors uppfattning om hemblodtrycksmätning. Metod: Studien har baserats på strukturerade intervjuer med barnmorskor vid 50 specialist-mödravårdsmottagningar i Sverige. I uppsatsen studerade och diskuterade möjligheten att erbjuda utvalda patienter hemblodtrycksmätning som en egenvårdsåtgärd och som ett alternativ till de besök hos barnmorskan som endast relateras till blodtrycksmätning. Resultatet: Hemblodtrycksmätning förekommer i begränsad omfattning i svensk mödrahälsovård. Av 50 undersökta specialistmödravårdsmottagningar i landet, använde endast 8 hemblodtrycksmätning. I de mottagningarnas vårdrutiner ges patienten möjlighet att välja hemblodtrycksmätning och att låna utrustningen gratis. Patienterna förefaller nöjda med och positiva till hemblodtrycksmätningen. Trots att några barnmorskor var skeptiska till metoden uttryckte majoriteten en positiv inställning till hemblodtrycksmätning. Slutsatsen: Hemblodtrycksmätning skulle kunna användas som en egenvårdsåtgärd och som ett sätt att öka förståelsen för det individuella blodtrycksmönstret. Den skulle samtidigt kunna bidra till att minska osäkerhet, beroendeställning och maktlöshet den som en del patienter känner i samband med blodtrycksavvikelser. Förhoppningsvis kan den också bidra till en tidig upptäckt av avvikande blodtryck hos kvinnan, vilket kan leda till ett snabbare och mindre dramatiskt omhändertagande.

Introduction. Allopregnanolone and pregnanolone (neuroactive metabolites of progesterone) act as positive modulators of the GABAA receptor system which is the major inhibitory system in CNS. Contradictory results on the effect of GABAA receptor modulators are reported. Beneficial properties such as anaesthesia, sedation, and anxiolysis are reported as well as adverse, anxiogenic and aggressive effects. It has been suggested that GABAA receptor agonists have bimodal effects. Low concentrations increase an adverse, anxiogenic effect, whereas higher concentrations show beneficial, calming properties. Aims. To investigate if progesterone treatment induces adverse mood in postmenopausal women and if the severity in mood symptoms is related to progesterone, allopregnanolone or pregnanolone serum concentrations. To evaluate differences in steroid concentrations induced by different doses and routes of administration of progesterone. Methods. Two randomised, placebo-controlled, double-blind crossover studies of postmenopausal women were performed. Subjects were treated with estradiol continuously. Different doses of progesterone, given vaginally or orally, were added sequentially during the last 14 days of each treatment cycle. Daily symptom ratings were kept using a validated rating scale. Blood samples for progesterone, allopregnanolone and pregnanolone analyses were collected during each treatment cycle. A study regarding the pharmacokinetics after ingestion of low-dose oral progesterone was conducted with postmenopausal women. Blood samples for the analyses of progesterone, allopregnanolone and pregnanolone were collected and pharmacokinetic parameters were calculated. Results. Certain postmenopausal women on sequential HT with vaginal and oral progesterone experience mood deterioration during the progesterone phase while on a low dose of progesterone but not on higher doses or the placebo. Negative mood symptoms occurred when the serum concentration of allopregnanolone was similar to endogenous luteal phase levels, whereas lower and higher concentrations had no effect on mood. Pharmacokinetic analyses show that low-dose oral progesterone can be used as a prodrug to allopregnanolone when the aim is to achieve physiological concentrations of allopregnanolone. Conclusions. A bimodal association between allopregnanolone concentration and adverse mood is observed in postmenopausal women treated with progesterone. The addition of low-dose progesterone to estradiol induces adverse mood in postmenopausal women, whereas higher doses and placebo have no mood-deteriorating effect.

<p>The aim of this thesis was to explore the prevalence of parentally experienced infant sleep problems, with special interest in severe problems, in a total community sample of 2 518 infants aged between 6 and 18 months. Factors associated with severe sleep problems were sought. Parents reported 16 % of the infants to have difficulties in falling asleep at night, and 30 % to have frequent night waking. Severe sleep problems were associated with frequent night meals, psychosocial problems in the family, exhaustion and depression in the mother, and parental stress. An association with infant difficultness, high activity and problematic behaviour was also found. </p><p>In a five-year prospective study a group of children fulfilling specific criteria for severe sleep problems in infancy (N=27) was followed after an interventional sleep programme and compared with a control group regarding sleep characteristics, behaviour and development. One month after an interdisciplinary treatment programme, combining behavioural technique with family work, the average number of times the case babies woke up had diminished from 6.0 to 1.8 times per night. A 92 % rate of improvement was reported.</p><p>The changes were stable over time. Comparisons with the controls during five years revealed no significant group difference in sleep characteristics. Concerning behaviour and development, however, there were significant differences. At the age of 5.5 years, seven of the children in the former sleep problem group met the criteria for the diagnosis of attention-deficit/hyperactivity disorder. No control child qualified for the diagnosis.</p>