Bakgrund: I Sverige år 2022 förlöstes färre än ett av tio barn som låg i sätesbjudning genom vaginal sätesförlossning. Om denna siffra slås ut på antalet barnmorskor i Sverige blir det tydligt att vaginala sätesförlossningar är något som är svårt att få praktisk erfarenhet av som barnmorska. Barnmorskan förväntas ha kompetens att kunna handlägga en vaginal sätesförlossning. Det råder nationell enighet i att vaginala sätesförlossningar bör handläggas av barnmorskor och obstetriker med god erfarenhet. Att uppnå god erfarenhet av vaginala sätesförlossningar kan ses som ett problem när majoriteten av sätesfödslarna sker med kejsarsnitt. Syfte: Att beskriva barnmorskors erfarenheter av att handlägga vaginala sätesförlossningar Metod: Datainsamlingen utfördes genom tio enskilda intervjuer. Som analysmetod valdes en kvalitativ innehållsanalys med en induktiv ansats. Resultat: Insamlade data genererade tre kategorier, Ryggsäcken barnmorskan bär på, Handläggning vid vaginal sätesförlossning och Faktorer som påverkar trygghet vid vaginal sätesförlossning med totalt åtta underkategorier. Barnmorskors syn och inställning till vaginala sätesförlossningar påverkas av tidigare erfarenheter. Barnmorskorna påtalar vikten av en lugn miljö vid en vaginal sätesförlossning samt diskuterar val av förlossningsposition. Teamet har en betydande roll för barnmorskornas känsla av trygghet och det uttrycks ett behov av utökad träning kring vaginala sätesförlossningar. Slutsats: Samtliga barnmorskor i studien uttrycker en vilja att bistå fler sätesförlossningar men att de ser ett behov av ytterligare träning och kompetensutveckling. Genom utökad träning och kompetensutveckling inom detta område kan teamet stärkas vilket på sikt skulle kunna öka barnmorskans trygghet vid handläggningen av vaginala sätesförlossningar. / Background: In Sweden in 2022, fewer than one in ten babies who were breech were delivered by vaginal breech birth. If this figure is divided between the number of midwives in Sweden it is difficult to gain practical experience with vaginal breech births as a midwife. The midwife is expected to have the competence to handle a vaginal breech birth. There is national consensus that vaginal breech births should be managed by midwives and obstetricians with good experience. Achieving that good experience with vaginal breech births can be a problem when most breech births are by caesarean section. Aim: To describe midwives' experiences of handling vaginal breech births Method: The data collection was carried out through ten individual interviews. A qualitative content analysis with an inductive approach was chosen as the analysis method. Results: Collected data generated three categories, The backpack the midwife carries, Handling of vaginal breech birth and Factors affecting safety during vaginal breech birth with a total eight subcategories. Midwives' views and attitudes towards vaginal breech births are influenced by previous experiences. The midwives point out the importance of a calm environment during a vaginal breech birth and discuss the choice of birth position. The team has a significant role in the midwives' sense of security and there is a need for increased training around vaginal breech births. Conclusion: All midwives in the study expressed a desire to assist more breech births, but they are aware of the need for continiuous training and skill development.  Through increased training and competence development in this area, the team can be strengthened, which in the long run could increase the midwife's safety when handling vaginal breech births.

Bakgrund: Endometrios är en kronisk sjukdom som kan ge olika symtom, inklusive svår menstruationssmärta, smärta vid samlag, fatigue och nedsatt fertilitet. Livet med endometrios påverkar individers fysiska, psykiska, sociala och existentiella välbefinnande i varierande grad. Sjuksköterskan har en central roll i att stödja patienter med endometrios genom att erbjuda trygg och kvalitativ omvårdnad med insikt i patientens perspektiv. Syfte: Att beskriva kvinnors upplevelse av att leva med endometrios. Metod: Metoden som användes var en allmän litteraturstudie med induktiv ansats där resultatet grundar sig i 13 vetenskapliga artiklar. Resultat: I litteraturstudien framkom olika upplevelser bland kvinnor med endometrios, inklusive fysiska, psykiska och sociala påverkningar. Deras möten med hälso- och sjukvården genererade både positiva och negativa erfarenheter. En brist på sjukvårdskunskap identifierades. Kvinnor kände sig inte tagna på allvar av sina anhöriga eller samhället och upplevde fördröjd diagnos samt brist på förtroende från vården. Det ledde till normalisering av deras symtom och försenad behandling, vilket förlängde deras lidande. När kvinnor träffade vårdpersonal som lyssnade uppmärksamt, kände de sig observerade, hörda och förstådda. Konklusion:  Endometrios har en omfattande och negativ påverkan på kvinnors liv i olika aspekter såsom fysiskt, psykiskt, socialt och även inom deras intima relationer. Sjuksköterskor behöver därför kontinuerlig kompetensutveckling för lindra lidande och erbjuda effektiv vård. / Background:  Endometriosis is a chronic disease that can present with various symptoms, including severe menstrual pain, pain during intercourse, fatigue, and reduced fertility. Living with endometriosis impacts individuals' physical, mental, social, and existential well-being in varying degrees. The nurse has a central role in supporting patients with endometriosis by providing secure and high-quality care with insight into the patient's perspective. Aim: To describe women's experience of living with endometriosis. Method: The method that was used was a general literature study with an inductive approach where the result is based on 13 scientific articles Results: In the literature study, various experiences emerged among women with endometriosis, including physical, psychological, and social impacts. Their encounters with healthcare generated both positive and negative experiences. A lack of healthcare knowledge was identified. Women felt not taken seriously by their loved ones or society and experienced delayed diagnosis and a lack of trust from healthcare providers. This led to the normalization of their symptoms and delayed treatment, prolonging their suffering. When women met healthcare professionals who listened attentively, they felt seen, heard, and understood. Conclusions: Endometriosis has a profound and negative impact on women's lives in various aspects, including physical, mental, social, and even within their intimate relationships. Therefore, nurses need continuous professional development to alleviate suffering and provide effective care.

Preeclampsia is a placental-related disorder characterized by generalized endothelial activation. Vascular predisposition is associated with the occurrence of preeclampsia and the recurrence risk is substantial. Onset of preeclampsia is preceded by placental hypo-perfusion, and placental over-production of vasoconstrictive agents might explain symptoms such as hypertension and proteinuria. Preeclampsia is associated with the birth of small-for-gestational-age (SGA) infants. The trajectory of postnatal growth in SGA-born children is described as catch-up, but it is unclear whether prenatal preeclampsia is independently associated with postnatal growth. The objectives were: firstly, to study the association between partner change and prior miscarriages on the occurrence of preeclampsia and SGA; secondly, to study postnatal growth in children prenatally exposed to preeclampsia; and thirdly, to address the association between blood pressure (BP) changes during pregnancy and risks of preeclampsia and SGA. Population-based cohort studies were performed with information from the following registers: Swedish Medical Birth Register, Uppsala Mother and Child Database and Stockholm-Gotland Obstetric Database. Associations were estimated with logistic and linear regression analyses, with adjustments for maternal characteristics, including body mass index, pre-gestational diseases and socioeconomic factors. The results were, firstly, that partner change was associated with preeclampsia and SGA birth in the second pregnancy but depended on the outcome of the first pregnancy, and that a history of recurrent miscarriages was associated with increased risks of preeclampsia and SGA. Secondly, prenatal exposure to preeclampsia was associated with increased offspring growth in height during the first five years. This association was also seen in children born with normal birth weight for gestational age. Thirdly, pre-hypertension in late gestation and elevated diastolic BP from early to mid-gestation were both associated with SGA birth. Further, women with pre-hypertension in early gestation without lowered diastolic BP until mid-gestation seemed to represent a risk group for preeclampsia. To conclude, the importance of previous pregnancy outcomes in the antenatal risk evaluation was highlighted. Secondly, the results imply that postnatal growth trajectory is related to maternal preeclampsia, in addition to SGA. Thirdly, the association between BP changes within a normal range and SGA may challenge the clinical cut-off for hypertension in pregnancy.

Background Advances in medical treatment during the last 50 years have resulted in more individuals with congenital heart disease (CHD) and Marfan syndrome reaching childbearing age. The substantial physiological changes during pregnancy result in a high-risk situation, and pregnancy is a major concern in women with these conditions. Aims To describe the socio-demographic characteristics, birth characteristics and reproductive patterns of individuals with CHD and women with Marfan syndrome. To investigate obstetric and neonatal outcomes in the firstborn children of individuals with CHD and women with Marfan syndrome. To study long-term cardiovascular outcomes after childbirth in women with Marfan´syndrome. Methods The studies are population-based register studies. The study population in the first paper included all women born between 1973 and 1983 who were alive and resident in Sweden at the age of 13 (494 692 women, of whom 2 216 were women with CHD). In the second paper, the same definition of the study population was chosen, except that it involved all men born between 1973 and 1983 (522 216 men, of whom 2 689 men with CHD). The third and fourth papers involved a study population of all Swedish women born between 1973 and 1993 who were still living in Sweden at age 13. This population consisted of 1 017 538 women, 273 of whom had been diagnosed with Marfan syndrome. Results and conclusions The individuals studied were more often born preterm, and were small-for-gestational age babies. They were more likely to have been born by cesarean section. In women with CHD, these characteristics were repeated in their firstborn children. No increased risks were found in children of men with CHD or in children of women with Marfan syndrome. There was no increased risk of aortic dissection in women with Marfan syndrome during pregnancy compared to women with Marfan syndrome who did not give birth. Higher frequencies of cardiac arrhythmia and valvular heart disease were found after childbirth in women with Marfan syndrome. Pregnancy in women with CHD is a high-risk situation associated with increased risk of adverse neonatal outcomes for the expected child. Pregnancy in women without CHD, but where the father has CHD is not so associated with increased risk of adverse obstetric or neonatal outcomes. Pregnancy in women with Marfan syndrome is not associated with adverse outcomes for the expected child.

INTRODUÇÃO: Sabe-se que as técnicas de reprodução assistida estão associadas com potenciais riscos, principalmente relacionados às gestações múltiplas, em torno de 20 a 25%, em consequência da estimulação ovariana associada à transferência de vários embriões. As gestações múltiplas apresentam maior incidência de complicações maternas e neonatais, além de aumentarem consideravelmente a proporção de partos cesarianos. Frente a esta realidade, as gestações múltiplas podem ser evitadas pela transferência eletiva de embrião único (eSET, do inglês elective Single Embryo Transfer), uma prática que vem crescendo em todo mundo. Apesar dos diversos estudos publicados, o grande desafio ainda é comprovar os benefícios da eSET aplicada corretamente, impactando na incidência das complicações sem comprometimento do sucesso do tratamento. O objetivo deste estudo foi comparar as taxas de sucesso cumulativas da transferência eletiva de até dois embriões transferidos um a um (eSET), versus a taxa de sucesso da transferência eletiva de dois embriões em um único evento (DET, do inglês Double Embryo Transfer), em casais inférteis de bom prognóstico. MÉTODOS: Estudo retrospectivo avaliou 610 casais inférteis de bom prognóstico submetidos às TRA, divididos em dois grupos: grupo SET: pacientes submetidas à transferência eletiva de um único embrião de boa qualidade e que possuíam ao menos um embrião excedente congelado (grupo SET, n=237), possibilitando uma segunda transferência eletiva de um embrião descongelado em caso de não ocorrência de gestação; e grupo DET: pacientes submetidas a transferência eletiva de dois embriões de boa qualidade e que possuíam ao menos um embrião excedente (grupo DET, n=373). RESULTADOS: As taxas de gestação clínica acumulada após a transferência de dois embriões foram semelhantes (DET: 46.6% e SET acumulado: 45,9%; p=0,898). Por outro lado, a taxa de gestação múltipla foi significantemente inferior no grupo que recebeu transferência de dois embriões um a um versus a transferência eletiva de dois embriões em um único evento (DET: 32,2% e SET acumulado: 6,1%; p < 0,001). CONCLUSÕES: A política de SET deve ser estimulada para casais de bom prognostico, já que resulta em taxas de gestação clínica acumulada semelhantes a DET, evita gestações múltiplas e consequentemente as complicações materno-fetais, levando a reduzido custo indireto do tratamento quando considera-se os gastos obstétricos e neonatais / INTRODUCTION: It is known that Assisted Reproductive Techniques are associated with potential risks, mainly related to multiple pregnancies, which are around 20 to 25% due to ovarian stimulation associated with high number of embryos transferred. Multiple pregnancies lead to higher incidence of complications for mother and newborns, as well as a significant increase in the proportion of cesarean deliveries. This way, iatrogenic multiple pregnancies can be avoided by the elective single embryo transfer (eSET), a growing practice worldwide. Despite the several published studies, adequately applied eSET, which impact on the incidence of complications without compromising treatment success, is still a challenge. The aim of this study was to compare the cumulative success rates of elective transfer of two embryos when transferred one by one (eSET), versus the success rates of elective double embryos transfer (DET) in a single procedure, in a good prognosis population. METHODS: This retrospective study evaluated 610 good prognosis infertile couples undergoing ART, split into two groups: SET group included those receiving elective single good quality embryo transfer and having at least one spared good quality embryo cryopreserved (SET group, n=237). For those who did not become pregnant, they could receive a second frozen-thawed elective embryo transfer; and DET group (n=373) who received elective transfer of two good quality embryos in the first transfer and had at least one spared good quality embryo cryopreserved. RESULTS: The accumulated clinical pregnancy outcomes after a transfer of two embryos were similar between groups (DET: 46.6% vs accumulated SET: 45.9%; p=0.898). On the other hand, the multiple pregnancy rate was significantly lower in the group receiving transfer of two embryos, one by one, compared to DET in a single procedure (DET: 32.2% vs accumulatedSET: 6.1%; p < 0.001). CONCLUSIONS: The SET policy should be stimulated for good prognosis couples, as it maintain the accumulated clinical pregnancy rates, avoid multiples pregnancies and consequently the maternal and neonates complication and indirect costs of treatment when considering obstetrics spends are reduced

Made available in DSpace on 2016-04-04T18:29:35Z (GMT). No. of bitstreams: 1 Eliane Gasparini.pdf: 2989781 bytes, checksum: 336ce92e619721141fd7369dba5d739c (MD5) Previous issue date: 2007-02-27 / This study relates the emotional experiences of infertile couples who decided to seek help in reproductive treatment. The objectives were: to investigate and analyze the main emotional reactions experienced by couples during the fertility treatment; to study the consequences of the reproductive treatment in couple s bonds as well as their bonds with the medical staff and the psychologist; to understand the psychic representations of the desire to have children when associated to a reproductive treatment, and to describe the psychologist s impressions and emotional experience in regard to the couples subjected to the study. Six couples with different medical diagnosis for infertility, seeking for medical treatment for such a problem were surveyed as primary source of information. For the purpose of the study were used methods and techniques such as the psychoanalytical method applied to the couple group ? special group ? according to K?es (1977) and Anzieu (1993), as well as he technique of non-directive interview of Bleger (1993), and the projective technique of free drawings. The technique of content analysis proposed by Mathieu (1967) and K?es (1977) was used to analyze the material collected. Psychoanalysis and group analysis theories were employed in the interpretation of couple s subjective experiences. From the analysis of the interviews and drawings, some elements in the couple s group mentality could be identified, among them the hipercatexization of the desire to have children. The difficulties associated to satisfying such desire unchained a regressive movement and also defensive reactions. The attempt to preserve omnipotent fantasies has compromised the process of tolerance to frustration and to the capacity to wait, or reformulation of the couple s projects. Persecutory-related anguishes were broken out, mainly in the elements of the couples whose personality aspects happened to be compromised the most. Infertility diagnosis as well as the various different fertility treatments led to the unstructuring of couple s bonds. We could observe the loss of intimacy and decrease in sexual desire after successive fertility treatments that break link between sexual intercourse and the reproductive act. Both the desire to transmit genetic heritage forward and the appreciation of biologic child are still part of couple s psychic representations. The biological-child, from the same blood, is the dreamt and idealized child. The satisfactory bond that the couple established with medical staff has interfered in how safe they feel and in their levels of hope and confidence that the fertility treatment will yield positive results. The majority of the couples managed to establish satisfactory bonds with the psychologist, using the interview session as a way to freely express their emotional experiences. The experience with infertile couples on one hand has allowed to increase their level of sensitivity in regard to the emotional phenomena associated to infertility, and on the other hand has helped such couples to think about appropriate means to deal with some problems that are a consequence of this situation. The method used in this study has assured good conditions for research and analysis once it has made possible the proper interpretation of the relationships between the elements of the couple, between the couple and the institution and of the couple and the psychologist. A work of such transference nature is based on the assumption that it is possible to understand the intensity of the psychic representations of the couple group. We recommend the creation of new environments where infertile couples can keep on freely discussing their desires, difficulties, fantasies and hopes, making it easier to understand the experiences originated from infertility. / Este estudo relata as viv?ncias emocionais de casais que apresentavam dificuldades para engravidar e que decidiram buscar ajuda na medicina reprodutiva. Os objetivos foram: investigar e analisar as principais rea??es emocionais desencadeadas no casal ao longo do tratamento para a infertilidade; estudar a repercuss?o do tratamento reprodutivo no v?nculo do casal, bem como do casal com a equipe m?dica e do casal com a psic?loga; compreender as representa??es ps?quicas em torno do desejo de ter filhos quando associadas a um tratamento reprodutivo, e descrever as impress?es e viv?ncias emocionais da psic?loga com rela??o aos casais estudados. Foram estudados seis casais, com diferentes diagn?sticos m?dicos para infertilidade, e que buscaram aux?lio na medicina reprodutiva. Utilizou-se o m?todo psicanal?tico aplicado ao grupo casal - grupo especial, conforme K?es (1977) e Anzieu (1993), assim como a t?cnica da entrevista livre n?o-diretiva de Bleger (1993), e a t?cnica projetiva do desenho livre. Para a an?lise do material coletado foi adotada a t?cnica de an?lise do conte?do proposta por Mathieu (1967) e K?es (1977), e para interpretar as experi?ncias subjetivas dos casais utilizaram-se as teorias da psican?lise e grupan?lise. A partir da an?lise das entrevistas e desenhos, alguns elementos foram identificados na mentalidade do grupo casal, entre eles a hipercatexiza??o do desejo de ter filhos. A dificuldade em atender a este desejo desencadeou um movimento regressivo e rea??es defensivas. A tentativa de preservar fantasias onipotentes dificultou o processo de toler?ncia ? frustra??o e ? capacidade de espera, ou reformula??o dos projetos do casal. Ang?stias de car?ter persecut?rio foram desencadeadas, principalmente naqueles c?njuges cujos aspectos da personalidade encontravam-se mais comprometidos. O diagn?stico da infertilidade, assim como os diversos tratamentos provocaram uma desestrutura??o no v?nculo conjugal. Observamos a perda da intimidade conjugal, a diminui??o do desejo sexual ap?s os sucessivos tratamentos que desvinculam as rela??es sexuais do ato reprodutivo. O desejo de transmitir a heran?a gen?tica e a valoriza??o do filho biol?gico ainda fazem parte das representa??es ps?quicas do casal. O filho biol?gico, do pr?prio sangue , ? o filho sonhado, idealizado. O v?nculo satisfat?rio que o casal estabelece com a equipe m?dica interferiu na sensa??o de seguran?a e esperan?a que os casais depositam no ?xito do tratamento. A maioria dos casais conseguiu estabelecer um v?nculo satisfat?rio com a psic?loga utilizando o espa?o da entrevista como forma de express?o livre das suas experi?ncias emocionais. A experi?ncia com os casais inf?rteis possibilitou por um lado sensibiliz?-los aos fen?menos emocionais diante da situa??o da infertilidade, e por outro, pensar em meios apropriados para resolver alguns dos problemas que surgem diante desta problem?tica. O dispositivo t?cnico que institui a interpreta??o para o trabalho psicanal?tico com os casais sobretudo aqueles inseridos na institui??o garantiu boas condi??es de pesquisa e an?lise, j? que possibilitou a interpreta??o necess?ria entre as rela??es dos membros do casal, entre o casal e a institui??o, e do casal com a psic?loga. Um trabalho desta natureza, de an?lise intertransferencial, baseia-se na concep??o de que ? poss?vel compreender a intensidade das representa??es ps?quicas do grupo casal. Recomendamos a cria??o de novos espa?os onde os casais inf?rteis possam continuar a discutir livremente sobre seus desejos, suas dificuldades, fantasias e esperan?as, facilitando a compreens?o das experi?ncias advindas com a infertilidade.

Background: Although giving birth is a positive experience for many, some 10% of pregnant Swedish women suffer from severe fear of childbirth (FOC), which impairs their daily functioning and poses a risk for a negative delivery experience. This thesis focuses on the mental and health-economic effects of severe FOC, and explores new treatment options for childbirth-related anxiety. Aims: (i) to investigate the prevalence of and variables associated with severe FOC, (ii) to estimate the cost of illness of severe FOC and (iii) to explore whether Internetbased cognitive behaviour therapy (ICBT) is feasible for treating pregnant women with severe FOC and those with childbirth-related symptoms of posttraumatic stress disorder (PTSD). Design and Results: Study 1: In a cross-sectional study 1635 pregnant women were asked about their FOC via the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), and provided socio-demographic data and information of their preferred mode of delivery. It was found that 15.6% of the participants had a severe FOC, which also strongly correlated with the preference of a caesarean section. Study 2: In a prospective case-control cohort study we mapped all visits, in-patient care, sick leave and delivery variables from medical records and estimated the societal costs in two groups of women; one group with severe FOC and one with low FOC. The costs for the group with severe FOC were 38% higher than for the low FOC group. Study 3: Twenty-eight nulliparous women with severe FOC were self-recruited to an eight weeks ICBT program for severe FOC. Fifteen women followed the entire program. Their FOC decreased significantly after treatment (Cohen’s d=0.95, p&lt;0.0001), which means that ICBT is feasible and an option for treating women with severe FOC. Study 4: Fifteen participants in Study 3 wrote narratives of the imminent delivery before as well as after therapy. After treatment, the women had a more realistic attitude towards childbirth, more self-confidence and more active coping strategies. Partners and staff were perceived as more helpful, and the women were more aware of the child they were bearing. Study 5: Fifty-six women with a traumatic delivery experience were included in a randomized wait-list controlled study (RCT) of the effects of an eight week long ICBT program for childbirth-related PTSD symptoms. These symptoms decreased in both groups during active therapy, while the between-group effect size varied depending on measurements. Psychiatric comorbidity decreased in both groups after active treatment. Conclusion: Severe FOC is prevalent among Swedish pregnant women, and the cost of illness of this marker of peripartum psychological vulnerability is considerable when treated using standard care. A new treatment option for this group with ICBT seems feasible and is associated with more realistic attitudes towards the imminent delivery. An RCT with eight weeks of ICBT for parous women with PTSD symptoms also had promising results. As severe FOC is prevalent and associated with mental and economic burdens for the individual and the society, there is an urgent need to expand the research field. It is important to find feasible and effective treatments that can be applied on a large scale. / Denna avhandling undersöker (i) hur vanligt det är att svenska gravida kvinnor lider av rädsla för förlossningen, och (ii) hur detta påverkar kvinnornas sjukvårdskonsumtion under denna period samt vilka kostnader detta innebär för samhället; testar och utvärderar (iii) nya behandlingsmetoder för rädsla för förlossningen och för posttraumatiska stressymptom efter en traumatisk förlossning. Avhandlingen består av fem delstudier: Studie 1 var en studie bland 1635 gravida kvinnor och visade att mer än var tionde gravid kvinna har svår förlossningsrädsla. Denna hade samband med kvinnornas önskemål om planerat snitt som förlossningssätt, och hos omföderskor, med tidigare negativa upplevelser av förlossningen. Studie 2 jämförde sjukvårdskonsumtion och sjukskrivning under graviditet och den första tiden efter förlossningen hos förstföderskor med svår respektive lindrig förlossningsrädsla, vilka omhändertagits i den ordinarie förlossningsvården. Gruppen med svår förlossningsrädsla visade sig ha avsevärt högre kostnader orsakade av att de i genomsnitt hade högre sjukskrivningstal under graviditet och fler besök på grund av psykiska besvär, samt oftare förlöstes med kejsarsnitt och hade komplicerade förlossningar. I Studie 3 testade 28 förstföderskor med svår förlossningsrädsla en ny behandlingsmetod med kognitiv beteendeterapi (KBT) via internet. Behandlingen medförde att kvinnornas rädsla kraftigt minskade från företill efter behandling. I Studie 4 skickade 15 av kvinnorna i Studie 3 in berättelser via nätet om hur de föreställde sig att deras förlossning skulle bli, såväl innan terapin startade som när den var avslutad. Efter genomförd terapi hade kvinnorna en mer realistisk attityd till förlossningen än före terapin och visade tecken på att ha ett bättre självförtroende och mer aktiva strategier att hantera den kommande förlossningen. Studie 5 utforskade om kvinnor, som upplevt en traumatisk förlossning, kan bli hjälpta av behandling med KBT via internet. Traumatiserade kvinnor slumpades till att antingen få behandling direkt eller få behandlingen efter en väntetid (kontrollgruppen). I båda grupperna minskade kvinnornas posttraumatiska stressymtom, liksom förekomsten av depression och andra ångestproblem. Sammanfattning: Avhandlingen visar att svår förlossningsrädsla är vanligt förekommande och medför lidande för kvinnor och ökade kostnader för samhället i samband med graviditet och förlossning, när detta problem hanteras i den vanliga vården. Två internetbaserade studier testar kognitiv beteendeterapi som behandling för svår förlossningsrädsla och för problem efter en traumatisk förlossning och visar att dessa behandlingsformer tycks fungera väl och i framtiden skulle kunna utgöra ett alternativ som medför att vård görs tillgänglig också för kvinnor som inte har tillgång till kvalificerade hjälpinsatser på andra sätt. Svår förlossningsrädsla och ångestproblem efter en traumatisk förlossning föreligger ofta tillsammans med annan psykisk sjuklighet varför diagnostik och behandling behöver utföras av personer med tillräcklig kompetens för dessa uppgifter. Otillräckligt behandlad/icke behandlad svår förlossningsrädsla ökar riskerna för att kvinnan upplever en kommande förlossning som traumatisk. Avhandlingens slutsatser behöver undersökas i fler och större studier, och, avseende behandlingsstudierna, i undersökningar som har tillräckligt stora kontrollgrupper. Om sådana studier bekräftar dessa preliminära fynd, blir frågan om screening för svår förlossningsrädsla aktuell eftersom det då finns såväl bra screeninginstrument som behandling som skulle kunna göras tillgänglig för stora grupper. Kommer samhället i denna situation att ha råd att inte försöka förebygga individuellt lidande och stora merkostnader för kvinnor med svår förlossningsrädsla? / Tämän tutkimuksen tavoitteena on tutkia (i) kuinka yleinen synnytyspelko on ruotsalaisten raskaana olevien naisten keskuudessa ja (ii) kuinka se vaikuttaa heidän terveyden‐ ja sairaanhoitopalveluiden kulutukseen raskauden aikana ja sen jälkeen, sekä selvittää miten synnytyspelko vaikuttaa yhteiskunnan kustannuksiin; kehittää, testata ja arvioida (iii) uusia hoitomuotoja synnytyspelon sekä synnytyksestä johtuvien psykologisen trau man (posttraumaattinen stressi, PTSD) hoitoon.' Tämä väitöskirja koostuu viidestä osatyöstä: 1. Ensimmäinen osatyö tutki synnystyspelon yleisyyttä 1635 raskaana olevan naisen keskuudessa. Tutkimus osoitti että joka seitsemäs raskaana oleva nainen Ruotsissa kärsii vakavasta synnytyspelosta. Keisarinleikkaus toiveen takana on usein vakava synnystyspelko. Uudelleen synnyttäjillä synnytyspelkoon vaikuttaa myös aiempi traumaattinen synnytyskokemus. 2. Toisessa osatyössa verrattiin ensisynnyttäjien terveyden- ja sairaanhoitokustannuksia sekä sairaslomapäiviä raskauden aikana, synnyksen yhteydessä sekä sitä seuraavan kolmen ensimmäisen kuukauden aikana. Vertailuryhmät seurasivat tavallista äitiysneuvolaohjelmaa, ryhmistä toisella oli vakava ja toisella lievä synnytyspelko. Vakavasta synnytyspelosta kärsivien naisten terveyden ja sairaanhoitopalvelujen käyttö osoittautui huomattavasti korkeammaksi kuin vertailuryhmässä. 3. Kolmannessa osatyössa 28 vakavasta synnytyspelosta kärsivää ensisynnyttäjää, testasi uutta ratkaisukeskeiseen terapiaan (KBT) pohjautuvaa Internetin kautta ohjattua psykologista hoito-ohjelmaa. Hoito lievensi huomattavasti osallistujien synnytyspelkoa. 4. Neljännessä osatyössä 15 naista (edellisestä osatyöstä 3) kirjoittivat osana terapiaansa kertomuksen tulevan synnytyksensä odotuksista. Sama tehtävä kertautui ennen terapian alkua sekä sen jälkeen. Kertomusten yhtäläiset teemat tunnistettiin minkä jälkeen ennen ja jälkeen hoitoohjelmaa kirjoitettujen kertomusten teemoja vertailtiin. Hoidon jälkeen naisten odotukset pohjautuivat suuremmassa määrin tietoon, he kuvailivat itsensä varmemmiksi sekä paremmin  valmistautuneiksi tulevaa synnytystä ajatellen. 5. Viides osatyö tutki Internetin kautta ohjatun ratkaisukeskeisen terapian (KBT) vaikutusta naisiin jotka kärsivät synnytyksen jälkeisestä henkisestä traumasta. Naiset satunnaistettiin tutkimuksessa joko välittömän hoidon ryhmään tai odotuslista ryhmään, joka sai saman hoidon myöhemmin. Hoidon jälkeen PTSD oireet vähenivät sekä hoitoettä kontrolliryhmässä. Myös masentuneisuus ja ahdistusoireet väheniväthoidon myötä. Yhteenvetona voidaan oheisista tutkimuksista todeta että synnytyspelko on yleinen ruotsalaisten raskaana olevien naisten keskuudessa. Synnytyspelko aiheuttaa kärsimystä sekä raskaana olevalle naiselle mutta myös lisäkustannuksia yhteiskunnalle. Kahdessa Internetin kautta ohjatussa ratkaisukeskeisessä hoito-ohjelmassa testattiin uusia hoitomuotoja raskaana oleville ensisynnyttäjille sekä synnytyksen jälkeisistä traumaoireista kärsiville naisille. Tulokset osoittavat, että Internetin kautta ohjattu hoito toimii näissä ryhmissä hyvin ja saattaisi tulevaisuudessa olla vaihtoehto kohderyhmille, joille sopivaa terapeuttista hoitoa nykytilanteessa ei voida tarjota. Koska vaikea synnytyspelko ja synnytystä seuraavat PTSD oireet esiintyvät usein muiden mielialahäiriöiden rinnalla, on tärkeää, että näitä naisia hoitavalla henkilökunnalla on tarpeellinen pätevyys hoitaa myös mielenterveysongelmia. Hoitamatta jätetty tai puutteelisesti hoidettu synnytyspelko lisää raskaana olevan naisen riskiä kokea synnytyksensä traumaattisena. Tulevissa tutkimuksissa tämän tutkimusprojektin tulokset ja johtopäätökset on syytä toistaa useammissa ja ennen kaikkea suuremmissa ryhmissä. Jos tutkimustemme alustaville tuloksille löytyy tukea, nousee kysymys synnystyspelon seulonnasta äitiysneuvoloissa ajankohtaiseksi; sekä seulontamenetelmä että tehokas hoitotapa ovat olemassa ja voitaisiin tarjota suuremmille kohderyhmille. Onko yhteiskunnalla sellaisessa tilanteessa varaa olla ennaltaehkäisemättä synnystyspelkoisten naisten kärsimystä?

INTRODUÇÃO: Sabe-se que as técnicas de reprodução assistida estão associadas com potenciais riscos, principalmente relacionados às gestações múltiplas, em torno de 20 a 25%, em consequência da estimulação ovariana associada à transferência de vários embriões. As gestações múltiplas apresentam maior incidência de complicações maternas e neonatais, além de aumentarem consideravelmente a proporção de partos cesarianos. Frente a esta realidade, as gestações múltiplas podem ser evitadas pela transferência eletiva de embrião único (eSET, do inglês elective Single Embryo Transfer), uma prática que vem crescendo em todo mundo. Apesar dos diversos estudos publicados, o grande desafio ainda é comprovar os benefícios da eSET aplicada corretamente, impactando na incidência das complicações sem comprometimento do sucesso do tratamento. O objetivo deste estudo foi comparar as taxas de sucesso cumulativas da transferência eletiva de até dois embriões transferidos um a um (eSET), versus a taxa de sucesso da transferência eletiva de dois embriões em um único evento (DET, do inglês Double Embryo Transfer), em casais inférteis de bom prognóstico. MÉTODOS: Estudo retrospectivo avaliou 610 casais inférteis de bom prognóstico submetidos às TRA, divididos em dois grupos: grupo SET: pacientes submetidas à transferência eletiva de um único embrião de boa qualidade e que possuíam ao menos um embrião excedente congelado (grupo SET, n=237), possibilitando uma segunda transferência eletiva de um embrião descongelado em caso de não ocorrência de gestação; e grupo DET: pacientes submetidas a transferência eletiva de dois embriões de boa qualidade e que possuíam ao menos um embrião excedente (grupo DET, n=373). RESULTADOS: As taxas de gestação clínica acumulada após a transferência de dois embriões foram semelhantes (DET: 46.6% e SET acumulado: 45,9%; p=0,898). Por outro lado, a taxa de gestação múltipla foi significantemente inferior no grupo que recebeu transferência de dois embriões um a um versus a transferência eletiva de dois embriões em um único evento (DET: 32,2% e SET acumulado: 6,1%; p < 0,001). CONCLUSÕES: A política de SET deve ser estimulada para casais de bom prognostico, já que resulta em taxas de gestação clínica acumulada semelhantes a DET, evita gestações múltiplas e consequentemente as complicações materno-fetais, levando a reduzido custo indireto do tratamento quando considera-se os gastos obstétricos e neonatais / INTRODUCTION: It is known that Assisted Reproductive Techniques are associated with potential risks, mainly related to multiple pregnancies, which are around 20 to 25% due to ovarian stimulation associated with high number of embryos transferred. Multiple pregnancies lead to higher incidence of complications for mother and newborns, as well as a significant increase in the proportion of cesarean deliveries. This way, iatrogenic multiple pregnancies can be avoided by the elective single embryo transfer (eSET), a growing practice worldwide. Despite the several published studies, adequately applied eSET, which impact on the incidence of complications without compromising treatment success, is still a challenge. The aim of this study was to compare the cumulative success rates of elective transfer of two embryos when transferred one by one (eSET), versus the success rates of elective double embryos transfer (DET) in a single procedure, in a good prognosis population. METHODS: This retrospective study evaluated 610 good prognosis infertile couples undergoing ART, split into two groups: SET group included those receiving elective single good quality embryo transfer and having at least one spared good quality embryo cryopreserved (SET group, n=237). For those who did not become pregnant, they could receive a second frozen-thawed elective embryo transfer; and DET group (n=373) who received elective transfer of two good quality embryos in the first transfer and had at least one spared good quality embryo cryopreserved. RESULTS: The accumulated clinical pregnancy outcomes after a transfer of two embryos were similar between groups (DET: 46.6% vs accumulated SET: 45.9%; p=0.898). On the other hand, the multiple pregnancy rate was significantly lower in the group receiving transfer of two embryos, one by one, compared to DET in a single procedure (DET: 32.2% vs accumulatedSET: 6.1%; p < 0.001). CONCLUSIONS: The SET policy should be stimulated for good prognosis couples, as it maintain the accumulated clinical pregnancy rates, avoid multiples pregnancies and consequently the maternal and neonates complication and indirect costs of treatment when considering obstetrics spends are reduced

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